Parent/Guardian Release Of Liability

Parent/Guardian Release Of Liability


 Boys & Girls Clubs of Elkhart County, Inc. doing business as Boys & Girls Club of Goshen, Boys & Girls Club of Elkhart, Boys & Girls Club of Middlebury, Boys & Girls Club of Nappanee and KidsCare, a Division of the Boys & Girls Clubs of Elkhart County, Inc. 

 Parent Authorization for Membership & Waiver of Liability

I, the undersigned parent or legal guardian of the minor child listed on this application (the “Member”), for myself, my heirs, assigns, personal representatives, next of kin, executors and administrators, on behalf of the Member, hereby RELEASE, WAIVE, ACQUIT and forever DISCHARGE the Boys & Girls Clubs of Elkhart County, Inc., KidsCare, a division of the Boys & Girls Clubs of Elkhart County, Inc., and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors, officers, employees, contractors, members, agents, or volunteers (collectively, the “Released Parties”), from all liability, claims, demands, or causes of action present or future, whether known or unknown, anticipated or unanticipated, that I or the Member might have against the Released Parties, for any reason, including NEGLIGENCE ON THE PART OF THE RELEASED PARTIES, and agree to indemnify and hold harmless the Released Parties from and against any and all claims, damages, and judgments, of whatever nature, including attorneys’ fees, that may be asserted or entered against any of them in connection with the Member’s use of facilities owned or controlled by the Released Parties, or participation in activities of the Member either at or away from the Boys & Girls Clubs of Elkhart County, Inc..

Medical Treatment

I give permission to the Boys & Girls Clubs of Elkhart County, Inc. to seek emergency medical treatment for the Member if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. I, the undersigned parent or legal guardian of the Member, further agrees to indemnify, defend and hold the Released Parties harmless from any and all liens, subrogation interests or third party actions for medical, hospital or surgical expenses and costs.

Data Collection

I give my permission to the Boys & Girls Clubs of Elkhart County, Inc. to collect information via online or written surveys, questionnaires, interviews, and focus groups from the Member. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or the Boys & Girls Clubs of Elkhart County, Inc. impact on our members.

School Information

I give my permission to the Boys & Girls Clubs of Elkhart County, Inc. and the following School Districts; Elkhart Community Schools, Concord Community Schools, Goshen Community Schools, Middlebury Community Schools and Wa-Nee Community Schools to exchange information regarding the Member. The purpose of the exchange is to help both organizations do a better job of helping the Member be successful in school, in the Boys & Girls Clubs of Elkhart County, Inc.) and in life. This release is valid for one year and may be revoked at any time by contacting applicable School District Boys & Girls Clubs of Elkhart County, Inc. in writing.

Data Sharing

I understand that the Boys & Girls Clubs of Elkhart County, Inc. may share information about the Member with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the Member’s school or school district, and other information collected by Boys & Girls Clubs of Elkhart County, Inc., including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.


As a member of the Boys & Girls Clubs of Elkhart County, Inc., the Member will have access to the Internet. While precautions are being taken, it is possible that the Member may access inappropriate sites. The Boys & Girls Clubs of Elkhart County, Inc. will have rules and consequences at the Boys & Girls Clubs of Elkhart County, Inc. for such behavior; however we will not be responsible for the consequences of such access.


Boys & Girls Clubs of Elkhart County, Inc. continues to monitor all updates from the Centers for Disease Control and Prevention (CDC)and Elkhart County Health Department for updated information, and is advising all staff, families, and youth members tocontinue taking precautions as recommended by the CDC.

I understand that even with enhanced precautions in place, Boys & Girls Clubs of Elkhart County, Inc. cannot guarantee that my child(ren) will not be exposed to COVID-19. I fully understand the risks involved, and I am making decisions for my family with this in mind. I agree to hold Boys & Girls Clubs of Elkhart County, Inc. harmless in the event of COVID-19 exposure.

I understand the Boys & Girls Clubs of Elkhart County, Inc. is not responsible for lost or stolen items. Parents and Boys & Girls Clubs of Elkhart County, Inc. members are responsible for their own transportation to and from the Boys & Girls Clubs of Elkhart County, Inc.. As a drop-in facility Boys & Girls Clubs are not responsible for Club members’ whereabouts. Note: KidsCare is a controlled access program. Parents are responsible for dropping their children off for morning sessions to their KidsCare site and picking them up from afternoon sessions at the KidsCare site. Transportation from KidsCare sites to schools and from schools to KidsCare sites is requested and arranged by the parent with the appropriate school transportation department. KidsCare and the schools’ transportation departments maintain appropriate communications with to assure that children are transported to and from KidsCare sites.

I give permission for the Member’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Clubs of Elkhart County, Inc. and its activities. I also understand who the Boys & Girls Clubs of Elkhart County, Inc. is not, nor does it claim to be, a licensed day care center. I have read the completed application and this form, understand the rules of the Boys & Girls Clubs of Elkhart County, Inc. and request the Member be admitted into membership.

I give my permission to the Boys & Girls Clubs of Elkhart County, Inc. and applicable school district to share information about Member with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by the Boys & Girls Clubs of Elkhart County, Inc. including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

KidsCare Payment Agreement Terms & Conditions

If payment is not received, your child(ren) will be withdrawn from the program and his/her place may be filled with the next child on our waiting list. KidsCare tuition is due in advance of service. This means you will pay each Friday for the upcoming week. The Annual $30 Registration Fee is due upon registration.

(RECOMMENDED) Option 1: Automatic Withdraw (Credit/Debit Card or ACH-Checking Only)

Sign up for automatic withdraw by enrolling online through the payment portal when you receive your first weekly invoice (via email). This is the recommended option for KidsCare payments. Automatic withdrawal carries over from school year to school year, but can be discontinued with one week’s notice at any time during the year by contacting the KidsCare billing at 574-533-4590 x205.

All automatic withdraw weekly payments will debit form your account on Friday to pay for the upcoming week.For ACH payments, please allow 1 to 3 business days for your payment to show up in your bank account.Any additional fees accrued to your account will automatically withdraw.

*An explanation of additional fees is provided at the end of this agreement and in the KidsCare Parent Handbook.

To Cancel Automatic Withdrawal: 

To cancel automatic withdraw, KidsCare must be notified at least one week in advance from the applicable payment date by contacting KidsCare at 574-533-4590 Ext. 219. If the automatic payment is not cancelled in time, the system will debit the payment from your existing account. 

To Change the Automatic Withdrawal Payment Method: 

To change automatic withdraw payment information, you may do so in the payment portal any time prior to the applicable payment date. 

Revocation of Automatic Withdrawal Payment Option:

Automatic withdrawal is an option offered for your convenience. To maintain access to the automatic withdrawal payment option, your account must remain in good standing. The automatic withdrawal payment option may be revoked for your account due to any of the following:

  1. Automatic payment has been returned due to insufficient funds (A service fee of $10 is charged for all returnedpayments.)
  2. The payment account account is closed, frozen, or expired
  3. The account number is invalid.

Option 2: Online One-Time Payments (Credit/Debit Card or ACH-Checking Only)

Weekly one-time payments can be made online through the parent portal. If you do not wish be on automatic withdraw please make sure the auto-enrollment box in the payment portal is not checked. You will receive an invoice via email each Friday for the upcoming week, and payment is due that same day. If paying by ACH please allow 1 to 3 business days for your payment to show up in your account.

A returned ACH payment will be assessed a $10 returned payment fee. This fee and all others must be paid before your child(ren) may return to KidsCare.

Option 3: Pay On-Site (Cash, Check or Money Order)

Payments may be made at your assigned KidsCare location by handing the payment directly to the KidsCare program staff and obtaining a receipt. For the safety of payment please do not give payment to school staff, school office or by placing payment into the child(ren)’s book bag. KidsCare is not responsible for payments given to school staff, handed in at the school office, or sent with your child(ren). Our team gives receipts for all cash, check and money order payments.

Cash Payments: No change will be given with cash payments. Please bring exact change. Any overage will be applied towards next week’s invoice. For your protection and ours, cash will be accepted with dual signatures on the receipt.

Payment by Check: Checks can be made out to KidsCare. The check must include your child(ren)’s name, site name, and the purpose of the payment (i.e. “weekly fee”). Please note: If your check is returned, you will be assessed a $10 service fee. This fee and all others must be paid before your child(ren) may return to KidsCare.

Additional Fees 

Additional fees may be assesed to your account. These fees may include but are not limited to:

  1. Returned Payment Fee: A $10 service fee is charged for all returned payments.
  2. Returned ACH Payments Fee: If an ACH payment is returned, a $10 service fee will then be assessed to youraccount.
  3. Late Pick-up Fees: See the KidsCare Parent Handbook for a description of these fees
  4. Add-On Service Fees: These are fees for services you have chosen to add such as 2-Hr Delays, Snow Days, etc.

All fees must be paid before your child(ren) may return to KidsCare.

Payment Summaries

KidsCare is not required to provide annual payment summaries (other than receipts upon payment). We ask that you keep record of your receipts for your own tax purposes. We strongly encourage you to pay through the online payment portal (Payment Options 1 & 2) so that you may view and download your statements there. KidsCare’s Tax ID # is 35-1033735

KidsCare Hours

Before School Program: 

  • Open from 5:30am to the start of school.
  • KidsCare sites open promptly at 5:30am. Please do not plan on dropping your child off before this time.

After School Program: 

  • Open from the end of school until 5:30 pm.
  • Sites close promptly at 5:30 pm, there is a penalty fee for children who are not picked up by 5:30pm.

Late Start & 2 Hour Delay Days: 

  • Open from 5:30 am until the start of school.
  • Please see the payment section to see options for Late Start and 2-hour Delay days.

Early Release Days: 

  • Open from end of school until 5:30 pm.
  • Please see the payment section to see options for Early Release days.

Membership Requirements

KidsCare is open to children ages 5-12 years old. Membership applications can be completed by a 

parent or guardian at any of our locations or on our website. Parents are asked to complete the application and pay the annual enrollment fee of $30.00 upon completion of this application. It is important that KidsCare has updated membership information. Please notify your KidsCare site staff of any changes of address or phone numbers.It is important to note that KidsCare cannot except:

  • Children who are not potty trained
  • Children with one on one needs
  • Children who fight, bite or flight

*All Kindergartners are on a probationary period of thirty days each school year.
(Individual cases will be determined by leadership groups.)

Change of Enrollment Status and Program Withdrawal

During enrollment, parents indicate their childs enrollment status for the year. Parents may change their child’s enrollment status by notifying KidsCare of the change at least one week in advance of when the new enrollment status should begin. Once your status changes, your billing and payments will change accordingly.Withdrawing from the program is a discontinuing of services for a period of 2 weeks or longer. To withdraw from the program, you must fill out a completed withdrawal form at the site and return to KidsCare staff 1 week prior to the intended withdrawal date. Failure to provide the completed form with a one-week notice will result in being charged for the following week. Payments are non-refundable without the completed form and notice.

Late Pick-Up Policy

We understand that problems arise from time to time that could prevent you from picking up your child on time. In that event, please call your KidsCare location as soon as you know you may be late and identify who will be picking up your child. 

If we have not heard from you by closing time, the person(s) listed on your authorized pick-up list will be contacted to pick up your child immediately. In the event that we are unable to contact you or your emergency contacts after closing time, the police or Department of Child Services may be contacted. Please discuss any questions about the late pick up policy with your KidsCare Site Coordinator. 

KidsCare closes at 5:30pm. Those parents whose children remain after KidsCare closes may be subject to the following late fees:

  • Late pickup (5:31-5:35) $5 per occurance
  • Late pickup (5:36-5:40) $10 per occurance
  • Late pickup (5:41-5:45) $15 per occurance

Every 5-minute increment after 5:45 will accrue another $5 until pick-up. *KidsCare site computer/tablet will be used to determine correct time of pick-up. Dismissal from the program may be deemed appropriate after the 5th late pick-up offense. Two written warnings will be provided to parents; fees will be assessed for any late pick-ups after that point. It is critical that parents ensure we have correct and updated phone, address and emergency contact information.

Receiving Invoices

KidsCare programs operate on a pre-paid weekly fee basis. Your first invoice will be emailed on or before your child(ren)’s initial start date and then every following Friday for the upcoming week. KidsCare uses an online billing system. Through the online billing system you can:

  • View invoice balance and account balances with payment portal
  • Have immediate access to all account activity
  • Add payment methods and make payments on invoices
  • Direct message KidsCare with your billing questions
  • Send us files or paperwork

Automatic withdrawal payments and/or one-time payments can be made through our online payment portal using Credit Card, Debit Card, or ACH-Checking. Cash, Check or Money Order payments will be accepted at your KidsCare location; however, we encourage you to take advantage of the online payment portal! 

You will receive instructions to set up your online account with your first weekly emailed invoice.

Behavioral Policy

Our goal at KidsCare is to provide a safe environment for all our members.

Every member is responsible for treating the site, team members, equipment, and other members with respect. Inappropriate behavior will be dealt with quickly, professionally, and with compassion. Below is a list of examples, but not limited to, inappropriate behaviors and their possible consequences.

Minor Incidents

  • Screaming/Yelling
  • Running in the cafeteria, halls, stairwells, etc.
  • Rough Housing
  • Name Calling / Teasing / Drama

Possible Consequences:

  • Warning / Activity Time Out
  • Parents to be Notified
  • Suspension from Program
  • Other Character-Building Options

Major Incidents

  • Disrespecting team members and volunteers
  • Bullying/Intimidating
  • Leaving the program without permission
  • Failure to follow directions
  • Being in an unsupervised area

Possible Consequences:

  • Notify Parents
  • Suspension from program
  • Termination from Program
  • Other Character-Building Options

Severe Incidents

  • Intent to Harm (Fighting, Punching, Biting, Spitting,etc.)
  • Threatening team members or KidsCare members
  • Stealing or Vandalizing
  • Inappropriate cell phone/social media use

Possible Consequences:

  • Notify Parents
  • Suspension from program
  • Termination from program
  • Other Character-Building Options


We ask that all parents and guardians make KidsCare staff at your site aware if your child(ren) are not going to be present that day.

Why Notify? – KidsCare wants to ensure your child is accounted for at all times. If you don’t let your site staff know about the absence, staff will call you to try and locate your child’s whereabouts. Please help us to make sure your child is safe by following this guideline. Safety is our first priority.

Who To Notify? – Please call or email the KidsCare site your child(ren) attends. If you call and there is not a direct line associated with your school site, please leave a message with the school or the KidsCare Administrative Office.

All email addresses and phone numbers associated with your KidsCare site can be found in the extra information portion of this handbook.

Inclement Weather

2-Hour Delays – If your school system calls for a 2-hour delay KidsCare is still open at 5:30am and is open an extra two hours. Please keep an eye out for any 2-hour delays that turn into closings. Please note: that if there is a closing after a 2-hour delay has been called, parents are required to retrieve their child(ren) already dropped-off by 8 am.

School Closure – If it becomes necessary for schools to close due to weather, KidsCare will also be closed. 

Closed Door Policy

KidsCare is a closed-door program which means that we do not accept drop-ins and every KidsCare member that enters our program must be signed in/out by their parent or guardian. KidsCare also monitors who comes in or out of our program area.

Release of Children Policy – Members will only be released to the primary parent/guardian (whoever filled out the registration form), and anyone the primary parent/guardian has put down as an emergency contact or alternative pick-up. Please keep this information up to date so there are no issues when it comes to picking up your child(ren). *Please note that all Parents/Guardians or emergency contact/alternative pick-ups will be asked for proof of identification when they pick up the first few times, until staff are familiar with that person.

Parent Expectations

Just as our members must observe specific rules in KidsCare, so too must all adults who enter our facilities. As role models, we expect that all adults entering our KidsCare program respect our rules. Profanity and/or inappropriate language will not be tolerated nor will violence or intimidation against staff, members, or other parents. We ask parent complaints are handled in writing and directly with the Site Supervisors. If these rules cannot be followed KidsCare reserves the right to remove you or your child from the program.

Parent Involvement & Visitation

We encourage parents to get involved in all aspects of their children’s lives. Parents are welcome to visit KidsCare at any time, but to enter our programs to participate they must seek approval from Area Manager/Area Director. In a similar way, a completed volunteer application is required if parents wish to interact with their children during program hours. The volunteer application requests consent for a background check. All adults who interact with any child during program hours must observe this policy to protect children.

Parent Concerns & Suggestions

We strive to exceed each parent’s expectation of our program by providing quality and structure in asafe and caring environment for your child(ren). If you have a concern or suggestion to improve our programs, please speak with the Site Supervisor. If you feel your concerns were not appropriately addressed, please call the Administrative Office at 574-534-5933.

Member Expectations for Program Participation

KidsCare positively impacts its members by offering a set schedule of fun & educational programming for all members. Participation in varied daily programming is expected by all members. As a member, your child is granted access to the regular programming as well as various specialized programs. Additional release forms may be provided for specialized programs. Additional explanation of any of our programs is available by request.

Outside Contact/Conflict of Interest

Boys & Girls Clubs of Elkhart County limits team members from forming any relationships with parents or families outside of our program that may be considered inappropriate. It is our policy that team members do not provide transportation to members in their personal vehicles without prior approval of Area Director or higher. We inform our team members that they are not allowed to communicate with members on social media. Please respect the professional boundaries of team members. If you have questions or concerns regarding this, speak to your KidsCare Site Supervisor.

Personal Belongings

Personal toys, video games, electronic devices, cameras and any other personal belongings will be left in member’s backpack unless given permission by KidsCare site staff for a scheduled activity such as parties or weekly fun days. Items used as coping tools will have to be approved by the KidsCare Area Director before implementation. KidsCare and team members are not responsible for lost or stolen items.

Electronics – All members are responsible for personal belongings. Valuables such as iPads, smart watches, headphones, speakers, and game systems should be left at home. Any such items may be held by the staff and returned to the parent upon leaving KidsCare. On scheduled days your child is permitted to use electronics, KidsCare staff reserve the right to check the electronic is being used appropriately, including checking in on the games/videos being played. No sharing of electronics of any form.

Cell Phones – We suggest that cell phones be turned off and placed in members’ backpacks. If a child’s cell phone interrupts programming, the phone may be retained by staff and returned to the child’s parent upon pick-up. We are not responsible for lost, stolen, or damaged cell phones. Disciplinary actions including suspension, will apply for frequent violations of this policy. Exceptions can be made at Area Director’s discretion. Members do not have permission to take photos and/or videos while at KidsCare. 

Movie Policy – It is our policy that KidsCare members watch movies that are only “G” or “PG” rated. Anything PG-13 or higher, would be provided to you as a parent and would require your signature for approval.

Toy Policy – Toys need to be left in backpacks or in lockers unless specified by KidsCare staff depending on parties and fun days. KidsCare does not allow any member to bring more than two toys to the KidsCare site for any occasion.


Please contact your community schools’ and transportation department insuring your child gets onto the correct bus for KidsCare. Please do so at least 3 business days prior to attendance. 

The above information applies only to those that ride the bus to a HUB site. If you have any questions regarding the above policy, please ask your site coordinator or call the KidsCare Administrative Office.

KidsCare Health

Medication Policy: Boys & Girls Clubs of Elkhart County staff members may not store or administer any medication at any time. If your child takes any prescription or non-prescription medications, it is the parent’s responsibility to make sure that child takes their medicine. Please contact the Area Director with any concerns. Parents and/or emergency contact must be available and will be expected to immediately pick up their child if there is a medical concern. *Please note that at no time is KidsCare responsible for your child’s prescription(s). KidsCare will not take prescriptions meant for the school nurses into our custody and give it to the school nurse upon their arrival. Any and all medications apply.

Medical Emergencies: Basic first aid supplies are available at each KidsCare site, and staff are trained in CPR/first aid. Parents/Guardians will be called if a child requires emergency care. In the case of an extreme emergency, KidsCare’s first call will be to 911 and the child will be taken directly to the Emergency Room. Parents will be notified directly after or in tandem with the emergency call.

Allergies: If you child has an allergy, please make sure to fill that information out on your child’s membership registration form so that we take the correct precautions when it comes to your child’s health. Please be aware that some of our sites may have a child that has peanut allergies, so please do not pack your child a snack that contains nuts. If there is ever any change in your child’s allergies, please update this information with your KidsCare site as soon as possible.

Illnesses: Children may become sick during their time at KidsCare. If your child becomes ill at KidsCare and we think it is better for him or her to go home rather than be in contact with other KidsCare participants, we will call and ask that you pick your child up within 1 hour of being contacted by KidsCare. This is for your child’s health as well as others in the program.

Temporary Exclusion: To reduce the spread of illness and maintain the health of all children at KidsCare, we may temporarily exclude your child form attending KidsCare. Please refer to the following section of illnesses that we cannot support at KidsCare, as well as the criteria required for return to KidsCare

In addition to the illnesses referenced in the following table, we may require health care provider clearance for other illnesses at our discretion.

Influenza/Flu accompanied with feverSigns of fever must be resolved for 24 hours without the use of fever reducing medications.
VomitingWhen symptoms are no longer present
Strep Throat or other streptococcal infection24 hours after initial antibiotic treatment and when fever is no longer present
Covid 19After 2-week quarantine period is concluded
Head Lice/Nits or other infestationsWhen all signs of lice/nits or other infestations are absent for a period of 24 hours.
Conjunctivitis (eye discharge) or Pink EyeWhen symptoms of red, watery eyes are resolved.
Fifth Disease (Human Parvovirus) accompanied by fever or behavioral change.When symptoms are no longer present.
Hand-Foot-and-Mouth Disease accompanied by either mouth ulcers or blisters, no control over drooling, fever or behavioral change.When your child has stopped drooling and does not have exposed open sores.
RingwormAfter treatment has started
Meningitis (Viral & bacterial)Health Care Provider Clearance
ScabiesAfter treatment has started
Fever ≥ 100oF (oral) If a child has signs or symptoms of illness their temperature will be taken orally to make sure your child is okay to continue their day at KidsCare.Signs of fever must be resolved for 24 hours without the use of fever reducing medications.
Soiled Clothing – Please note that KidsCare members cannot ride the bus to their home school with soiled clothes due to health concernsWhen the child is clean and has changed out of their soiled clothing.


Enrollment Fee: $30 per school year

Enrollment Fee is due with your first weekly payment Enrollment Fee is non-refundableIf no payment is received and/or you withdraw your child(ren), your child(ren)’s spot will be forfeited and will be given to the next child on the waiting list.

Weekly Fees based on Status:

KidsCare programs operate on a weekly fee basis. Weekly Fees are based on the member status selected. Fees are based on enrollment, not attendance or whether school is in session; the exception being Spring Break, Winter Break and those districts who participate in a week-long Fall Break. Fees will begin based on the start date provided. KidsCare does not pro-rate partial weeks. An invoice will be emailed on or before the initial start date and every Friday for the upcoming week. Payments are due in advance on Friday to pay for the upcoming week. Your child(ren) will not be able to attend without payment.

AM or PM Care: $55 per week per child

AM & PM Care: $75 per week per child

Wednesday AM Late Start Care for Middlebury Community Schools: $15 per week per family. No additional fee is charged for members already paying for AM care.

2 Hr. Delay Care: $15 per family when utilized. No additional fee is charged for members already paying for AM care.

*There is a 5% discount for all families where at least one parent works for oneof our 5 school districts. (Concord, Elkhart, Goshen, Middlebury & Wan-Nee)*

Financial Aid

Note: Limited Financial Aid is available for each school year and you must re-apply each year

  • Ask your Site Program Coordinator for a Financial Aid application or call KidsCare at 574-533-4590.
  • Income restrictions apply
  • If no payment is received and/or you withdraw your child(ren), your child(ren)’s spot will be forfeited and will be givento the next child on the waiting list.