Pedersen-McCormick Boys & Girls Club Membership

Confidentiality: Any confidential information requested is for our records and for the funding our organization receives. The answers you provide will be kept confidential. Your cooperation in providing this information is both appreciated and necessary. Required fields are denoted with asterisks.

Please share information for additional contacts who can be notified in case of emergency, and who have permission to pick up the Club member:

Boys & Girls Clubs of Chicago (BGCC) will gather data to evaluate the Club’s progress toward meeting Club program objectives, analyze areas of potential program improvement, and better communicate impact to parents, donors, and the community. In particular, BGCC will gather member data to determine how Club attendance makes an impact in several areas, including academics, character, and health. A portion of this analysis will be done utilizing student information from Chicago Public Schools (CPS). With your permission, BGCC would like to collect the following information from your child’s CPS school records through the current school year: Grade Level, Grades, Standardized Achievement Test Scores, Attendance Information, and Number of Days Suspended. This data will be collected on a periodic basis using your child’s CPS student ID number, analyzed against BGCC attendance data, and then reported for the Club as a whole. These reports may be used internally for program improvements or communicated externally to the community, youth, parents, and existing or potential donors and funders. Member information will remain strictly confidential and will only be used by BGCC, its staff, and long-standing technology partner nFocus Software. Strict guidelines are in place to ensure confidentiality, and each party has received appropriate training. At no point will individual student data be publicly released.

I have read the completed application, understand the rules of Boys & Girls Clubs of Chicago (BGCC), and request that my child be admitted into membership. I have explained the rules to my child and agree that BGCC will not be responsible for any accident to the child while on BGCC premises or while engaged in any activities away from BGCC. I give my consent for photographs, video, or other media in which my child may appear, to be used in any way BGCC chooses, and for my child to participate in media opportunities overseen by BGCC. I also give consent for my child to participate in the periodic outcome measurement surveys, focus groups and other evaluation tools administered by BGCC and its authorized partners – including for BGCC to include my child in focus groups conducted by internal staff members or by consultants working on behalf of BGCC for the purpose of obtaining youth feedback and insight – and for BGCC to receive my child’s grades and other academic data from their school for the purposes detailed above.