Member Full Name:_____________________________________ Member Birthdate:_______________

__________________ _____________________________ _______________________________

Date Printed name of Parent/Guardian Signature of Parent/Guardian By signing above, I agree that I have read this form in its entirety and agree to adhere to the rules set forth by BGCTM.

WAIVER OF LIABILITY AND DISCLAIMER: In consideration of my child(ren)’s membership and participation in the activities,

special programs, and/or events of the Boys & Girls Club, I hereby fully waive, release, and hold harmless the Boys & Girls Club of

Truckee Meadows, together with all its agents, employees, representatives, officers, and directors from any and all claims, causes

of action, damages, costs, expenses, and other liabilities in any way arising out of or resulting from such membership or participa-

tion, including, but not limited to, any personal injury, accident, illness, property damage, or any other loss, injury, or harm whatso-

ever. I attest and verify that I have full knowledge of any and all risks involved in such membership and participation, and that I

will, on behalf of the named member(s), assume full responsibility for such risks and pay any and all medical, emergency, and other

costs and expenses in the event of injury, accident, illness, casualty or other incapacity regardless of whether I have authorized

such expenses. I acknowledge that my child(ren) is/are in good health, physically fit, and sufficiently trained to participate in mem-

bership and in the programs, activities and events of the Boys & Girls Club.

ACKNOWLEDGMENT AND CONSENT: For both internal and external use, I acknowledge that the Boys & Girls Club and/or its

sponsors may utilize photographs or video of the named child(ren) that may be taken during involvement in the Boys & Girls Club

programs or activities for publications and the Club’s website use. Their last names will never be mentioned in these pictures or

videos. I consent to such uses and hereby waive all rights of compensation. I understand the Club has adopted a Safe Passage Poli-

cy that prohibits members from coming and going as they please. I understand that once a child has entered the building, they will

not be allowed to leave until a parent/guardian/authorized adult arrives to retrieve them. I understand that the Club is not a li-

censed day care facility and that the staff will not physically restrain children who insist on leaving without parent permission.

MEMBERSHIP APPLICATION: Annual Membership Fee is $20.00. This fee is non-refundable/non-transferable. If your child has

an Anthem Blue Cross & Blue Shield Healthcare Solutions (Amerigroup) insurance card their Annual Membership Fee for the year

will be waived. If the Parent / Guardian has an active military ID available for verification, please see the Coordinator to fill out

Military Brochure to waive Annual Membership Fee. Membership runs from June 1st, 2019—May 31st, 2020.

I, the undersigned, have reviewed and verified the Membership Application, and all of its contents.

Safe Passage Policy: If you would like your child to leave the building with or without an authorized minor, who is under the age

of 18, please refer to the back of this page, list all that comply within the rules, and date and sign the bottom.

I, the undersigned, understand by initialing below that I have read and understand the rules and regulations of the

Boys & Girls Club of Truckee Meadows.

______: Food Program (Page 1.1), The Boys & Girls Club of Truckee Meadows Policies (Page 1.2),

Waiver of Liability and Disclaimer (Page 1.3), Acknowledgement and Consent (Page 1.4),

Emergency Authorization (Page 1.5),

______: Safe Passage Policy (2.1), E-mail and Technology Acceptable Use Policy (Page 2.2),

Medication Release (2.3), Phone Calls (2.4)

______: Bussing / Shuttle Policy (3.1)

______: Before / After School Program Consent Form (4.1)

______: Summer, Fall, Winter and Spring Break Consent Form (5.1)

: By checking this box I certify that I have watched the orientation video in its entirety, or have sat through an in-person ori-entation presentation and I fully understand all of the information communicated to me. I have no further questions at this time

and know that if I have questions in the future, I can contact 775-331-KIDS for answers.

Authorization to Leave Premises Unescorted Please Initial In Box

My child is 13 years or older and has my permission to check him/herself out of the Club.

My child is younger than 13 years old, but has my permission to leave the club with _______________________.

Age: __________ Relationship:__________________________

I understand the Club has adopted a Safe Passage Policy that prohibits members from coming and going as they please. I

understand that once a child has entered the building, they will not be allowed to leave until a parent/guardian/authorized

adult arrives to retrieve them. I understand that the Club is not a licensed day care facility and that the staff will not physi-

cally restrain children who insist on leaving without parent permission. By signing this form, I understand this policy.

Signature of Parent/Guardian: _____________________________________ Date: ______________

__________________ _____________________________ _______________________________

Date Printed name of Parent/Guardian Signature of Parent/Guardian

Members must scan in and out each day;

Members 12 and younger must be escorted from the Club by a parent, guardian, or other authorized

adult;

Authorized adults who escort members must enter and exit through a designated door;

Members age 13 and older may leave the Club unescorted with written permission from a parent or

guardian and a signed release of liability (below);

Members 13 and older may also escort other members of their household from the Club (with written

permission below);

No unescorted member, regardless of age, will be allowed to return to the Club once they leave the

premises for the day;

The Club will not physically restrain a member who insists on leaving the Club, nor block the facility’s exit.

Staff will not respond to phone calls requesting a member to be dismissed unescorted;

Members that leave unescorted without written permission will face disciplinary actions up to and includ-

ing suspension and termination of membership; This policy may vary from site to site and variations may

be set forth by the Executive Director.

SAFE PASSAGE POLICY 2019-2020

By signing above, I agree that I have read this form in its entirety and agree to adhere to the rules set forth by BGCTM.

PARENT/GUARDIAN CONSENT FORM

I, the parent or legal guardian for _______________________ hereby give my permission for my child to participate in the Mentoring Program at the Boys & Girls Club.

I fully understand that the program involves mentors, who shall be selected from the commu-nity and will be screened (including a criminal background check) and trained before begin-ning in the program. A mentor will be expected to spend a minimum of one hour per week with my child on-site at the Boys & Girls Club. The mentor is not allowed to take or meet my child beyond the Club facility.

I understand that my child will participate in an orientation session at the Club in which the program will be explained. The program is planned to last one year and continuation may then be discussed.

I understand that during the course of the mentoring program there may be special group events (incorporating all mentors and youth) and family events planned. I understand that the staff of the Club will provide ongoing monitoring of the mentoring activities.

I give the Boys & Girls Club Mentoring Program Coordinator permission to obtain my child's academic and attendance records from my child's school.

I permit the Mentoring Program staff and the Boys & Girls Club to utilize photographs of my child taken during his/her involvement in the mentoring program and waive all rights of com-pensation.

_____________________________________

(Signature of Parent/Guardian)

_____________________________________

(Printed name of Parent/Guardian)

Date__________________

Please sign the permission form and return to the Boys & Girls Club Mentoring Program Coordinator .

Thank you!

FORMULARIO DE CONSENTIMIENTO DE PADRE/MADRE O ENCARGADO

Yo, padre, madre o tutor legal de _____________________ autorizo a que mi hi-jo___________________ participe en el programa de mentoría del Boys & Girls Club. Entiendo totalmente que en el programa participan mentores, quienes serán se-leccionados en la comunidad. Y a quienes se les hará una verificación de antece-dentes (incluyendo antecedentes penales). Además los mismos serán adiestrados antes de comenzar en el programa. Se espera que el mentor pase al menos una hora por semana con mi hijo/a en el Boys & Girls Club. El mentor no está autoriza-do a salir ni a compartir con mi hijo/a más allá de las instalaciones del Club Entiendo que mi hijo/a participará de una sesión de orientación en el Club en la que se le explicará el programa de mentoría. Se espera que el programa tenga una duración de un año. Entiendo que durante el curso del programa de mentoría pueden haber eventos especiales grupales (reuniendo a todos los mentores y a los participantes), al igual que eventos familiares. Entiendo que el personal del Club estará continuamente monitoreando las actividades del programa de mentoría. Autorizo al Coordinador del programa de mentoría del Club a obtener el record académico y de asistencia de la escuela de mi hijo/a. Autorizo al personal del programa de mentoría y al personal del Boys and Girls Club a tomar y a utilizar fotografías de mi hijo/a durante su participación en el programa de mentoría, renunciando así a todos los derechos de compensación. _____________________________________ (Firma del padre/madre o tutor legal)

_____________________________________ (Nombre de padre/madre o tutor legal) Fecha__________________

Favor firma la hoja de consentimiento y devolver el documento al personal Coordinador del Programa de

Mentoría del Boys & Girls Club.

¡Gracias!

2019-2020 Liability Waiver Information

(1.2) THE BOYS & GIRLS CLUB OF TRUCKEE MEADOWS POLICIES: All children visiting the Club MUST be registered members to be covered by our general insurance policy. As a courtesy and, in cases of questionable inclement weather, it is the parent’s/guardian’s responsibility to contact the Club and verify transportation and to make other arrangements if our buses are not running. The membership fee is an annual, non-refundable fee.

(1.3) WAIVER OF LIABILITY AND DISCLAIMER: In consideration of my child(ren)’s membership and participation in the activities, special programs, and/or events of the Boys & Girls Club, I hereby fully waive, release, and hold harmless the Boys & Girls Club of Truckee Meadows, together with all its agents, employees, representatives, officers, and directors from any and all claims, causes of action, damages, costs, expenses, and other liabilities in any way arising out of or resulting from such membership or participation, including, but not limited to, any personal injury, accident, illness, property damage, or any other loss, injury, or harm whatsoever. I attest and verify that I have full knowledge of any and all risks involved in such membership and participation, and that I will, on behalf of the named member(s), assume full responsibility for such risks and pay any and all medical, emergency, and other costs and expenses in the event of injury, accident, illness, casualty or other incapacity regardless of whether I have authorized such expenses. I acknowledge that my child(ren) is/are in good health, physically fit, and sufficiently trained to participate in membership and in the programs, activities and events of the Boys & Girls Club.

(1.4) ACKNOWLEDGMENT AND CONSENT: For both internal and external use, I acknowledge that the Boys & Girls Club and/or its sponsors may utilize photographs or video of the named child(ren) that may be taken during involvement in the Boys & Girls Club programs or activities for publications and the Club’s website use. Their last names will never be mentioned in these pictures or videos. I consent to such uses and hereby waive all rights of compensation. I understand the Club has adopted a Safe Passage Policy that prohibits members from coming and going as they please. I understand that once a child has entered the building, they will not be allowed to leave until a parent/guardian/authorized adult arrives to retrieve them. I understand that the Club is not a licensed day care facility and that the staff will not physically restrain children who insist on leaving without parent permission.

(1.5) EMERGENCY AUTHORIZATION: I, the undersigned, as a parent/guardian of the named minor child(ren), hereby authorize the staff of the Boys & Girls Club, its sponsors, and vehicle drivers as my agents, to consent to medical, surgical, dental examination, or treatment and/or care at any hospital or by licensed medical personnel.

(1.1) THE FOOD PROGRAM: The Food Program at the Boys & Girls Club of Truckee Meadows participates in

the Child and Adult Care Food Program (CACFP), as well as the Summer Food Service Program (SFSP), federal pro-

grams that provides healthy meals and snacks to children receiving after school and summer care. In accordance

with Federal law and U.S Department of Agriculture policy, the Boys & Girls Club of Truckee Meadows is prohibit-

ed from discriminating on the basis of race, color, national origin, gender, age, or disability. If you have a ques-

tion about CACFP or the SFSP, please contact Mike Wurm, Executive Director of the Boys & Girls Club of Truckee

Meadows, at (775)331-5437 or The Nevada Department of Agriculture at (702)668-4585. Additional costs for the

Food Program at the Club are, in part, absorbed by the William N. Pennington Foundation. This institution an

equal opportunity provider.

(2.1) SAFE PASSAGE POLICY

Members must scan in and out each day;

Members 12 and younger must be escorted from the Club by a parent, guardian, or other authorized adult;

Authorized adults who escort members must enter and exit through a designated door;

Members age 13 and older may leave the Club unescorted with written permission from a parent or guardian and a signed release of liability;

Members 13 and older may also escort other members of their household from the Club (with written permission);

No unescorted member, regardless of age, will be allowed to return to the Club once they leave the premises for the day;

The Club will not physically restrain a member who insists on leaving the Club, nor block the facility’s exit.

Staff will not respond to phone calls requesting a member to be dismissed unescorted;

Members that leave unescorted without written permission will face disciplinary actions up to and includ-ing suspension and termination of membership;

This policy may vary from site to site and variations may be set forth by the Executive Director.

(2.3) RELEASE FOR MEDICATIONS:

It is understood that Boys & Girls Club of Truckee Meadows will hold one day’s worth of medication at a time

for a member and only with the understanding that the child knows it is their responsibility to come and

medicate. It is understood that medication must be in a bottle with the member’s name with time and dos-

age printed clearly on the bottle. The Boys & Girls Club of Truckee Meadows will not take any bottle for

which we do not have a proper prescription bottle or the “Administer Medication Permission Form”. No one

on staff is a licensed medical provider.

Members are responsible for getting their medication from the Site Coordinator at the appropriate time

and taking their medication.

(2.4) PHONE CALLS: As a general rule, members may not receive phone calls. If there is an emergency, please call the club and we will

transfer the call to the appropriate Site Coordinator to pass along a message to the member.

Members may not use the Boys & Girls Club phones. Members may use the phone during closing time to ensure

an authorized pickup is on the way.

If a child calls 911 without an emergency from the club, it is considered a crime by our local law enforcement agen-

cies. Reno Police Department may trace the call and the parents may be charged with a misdemeanor. In addition,

the member may face suspension from the club.

(2.2) E-MAIL AND TECHNOLOGY ACCEPTABLE USE POLICY: I, the undersigned, have given my e-mail

address as permission to receive e-newsletters regarding upcoming activities at the Club. At any time, I may

contact the Boys & Girls Club of Truckee Meadows to be removed from this mailing list. I have also received

and understand the Technology acceptable use policy for The Boys & Girls Club of Truckee Meadows.

(3.1) Bussing/Shuttle Policy 2019-2020

During after school and field trips, we expect your child to be on their best behavior while in the buses or our vehicles.

They must sit down, talk QUIETLY, and follow the bus or shuttle driver’s directions. Failure to do so may result in

suspension from the bus which will be given at the driver's discretion.

Bus and shuttle warnings & suspensions are for our Transportation only. If a member receives a suspension, that

member will lose the right to ride on the buses, our shuttles and vans for a period of time. This will include field trips

that the member is registered to go on. Credit for missed field trips will not be given for misbehavior.

Bus suspension will be determined by the site coordinator/staff and the Bus Driver. Parents will be informed accordingly.

Rules for the Bus/Shuttle:

1. A valid Boys & Girls Club Membership Card is required to board any bus, shuttle or van.

2. Backpacks must be taken off before sitting in a seat.

3. Always walk to and from the bus area.

4. Stand back from the curb.

5. Please be kind to others around you, keeping hands to your self.

6. On the bus, remain seated at all times. You may have an assigned seat.

7. Only use indoor voices on the bus. Inappropriate language is not acceptable.

1. Eating and drinking is not permitted while on the bus.

2. Keep your hands and feet to yourself and out of aisles.

3. All parts of your body need to stay in the bus. (ex: arms out of the window)

4. Until the door is completely open, you must stay in your seats.

5. Crawling under the bus for any reason is dangerous and is prohibited!

6. All of your property must stay out of the aisles.

7. If a Member damages the school bus or shuttle, their parents will be responsible for the cost of repairs and damages.

8. Large objects, animals and weapons are not allowed on any bus.

9. Railroad crossings require children to be quiet at all times.

17. Boys & Girls Club of Truckee Meadows is not responsible for children that miss the shuttle to the after school program.

Consequences for not following these rules:

1. Driver/BGC staff issues an incident report. 2. Citation given and a suspension for up to 3 days will

occur. (Bus and possibly BGC) 3. Citation 2 will result in a 5-10 day suspension. (Bus and

BGC) 4. Citation 3 will result in a parent conference and possi-

ble long-term suspension from the club.

Certain situations may result in automatic

suspension from Bus and BGCTM:

1. Physical threats and/or harm to another member or driver.

2. Fighting, carrying weapons, smoking, or drugs on the bus.

3. Damage of any property.

4. Constant disobedience.

5. Severe and/or total disruption.

6. Bullying.

(4.1) AFTER SCHOOL PROGRAM (August 2019-MAY 2020) MEMBERSHIP FEES and PAYMENTS

1. Boys & Girls Club Annual Membership is $20.00. This fee is non-refundable/non-transferable. This fee makes your child a

current member until May 31, 2020 and includes eligibility to participate in the different programs throughout the Club. These would include but are not limited to:

1. The After School Program, intersession break programs, sports leagues. There are some programs that cost an additional fee.

2. Transportation from select schools to the following club houses: DWR, Pennington, Neil Road, DLC, and Lemmon Valley.

3. All locations will have a fee of $15 per week / per child for the before school program and $25 per week / per child for the after school program. There is no pro-rating for these fees. Please see a Site Coordinator about sibling, daily, and monthly rates.

AFTER SCHOOL HOURS (August-May)

1. DWR: Monday-Friday 6:30am – 9:am and 2:00pm - 7:00pm. Dinner/snack is served.

2. Pennington: Monday-Friday 7:00am - 9:00am and 2:00pm - 7:00pm. Dinner/snack is served.

3. Neil Road: Monday-Friday 2:00pm - 7:00pm. Dinner/snack is served.

4. Lemmon Valley: Monday-Friday 7:00am - 9:00am and 3:30pm-6:30pm. Dinner/snack is served.

5. Donald L. Carano: Monday-Friday 7:00am - 9:00am and 2:00pm-6:00pm. Dinner/snack is served.

6. School Site Locations: Monday-Friday 7:00am - 9:00am and the after school program runs for 3 hours after the last bell rings.

7. Fernley Locations: Monday-Friday 6:30am - first bell and last bell - 6:00pm.

8. Holidays: DWR/Pennington/Neil Road/Donald L. Carano/Lemmon Valley operate 7:00am-6:00pm (Fernley 6:30am-6:00pm). These days are free, breakfast and lunch are included. (Please reference your Membership Handbooks for a list of Holiday clo-sures.)

9. It is the parent’s responsibility to verify if the Club is open in the case of snow days or inclement weather.

10. Early releases and conference weeks are accommodated.

AFTER SCHOOL BUSSING PROGRAM (August-May)

1. To be eligible for bussing from select schools, parents must sign the Bussing/Shuttle Policy Form.

2. Payment for the before/after school program is due the week prior to attending by closing on the last open business day.

3. Members need to be waiting outside for the busses immediately after school.

4. If your child misses the bus, they need to go to the school office to call us. The sooner they notify us, the more likely we will be able to turn back for the child. THERE IS NO GUARANTEE THE BUS WILL GO BACK.

5. There is NO home bussing. Children must be picked up at the Club no later than their Clubs’ closing time.

GUIDANCE and DISCIPLINE POLICY

The Boys & Girls Club of Truckee Meadows wants to keep the Club environment as safe as possible for not only the kids but also the staff. We have a discipline policy in which warnings, citations, and possible suspension in order to keep the environment at the Club a positive place to be for everyone.

LATE POLICY FOR AFTER SCHOOL PROGRAM: PLEASE NOTE: THERE IS NO GRACE PERIOD AFTER CLOSING TIME

**If a parent is later than closing time, this will result in a late pickup notice. **Three late pickup notices may warrant suspension from the Club for the member.

**15 minutes after closing, we may enforce an automatic suspension with no credit for payments.

We reserve the right to call d Reno Police Department (R.P.D.) and/or Child Protective Services (C.P.S.) as of 15 minutes after closing if we

are unable to reach an adult by phone.

(5.1) SUMMER, FALL, WINTER and SPRING BREAK 2019-2020 PARENT CONSENT FORM

BREAK PAYMENTS

1. Break Fees, field trips, and specialty camps are non-refundable and non-transferable.

2. The weekly fee is $40.00 per week / per child regardless of days and hours attended. There is No Pro-rating.

3. Financial Assistance is available to help possibly reduce the weekly fees. All adults in the household must provide proof of income and will be required to submit one month of most recent paycheck stubs to verify income. Fees are then based off household size and income.

4. Payments for Break Sessions, Specialty Camps, and Field Trips are due by closing time on the last business day before each session. (Friday’s by closing unless Clubs are closed, then prior.)

5. We accept exact cash, pre-printed checks (not postdated), money orders, and VISA/MASTER CARD. Completed session forms and payments can be made to the Membership Coordinator, Site Coordinator or front counter staff. We are not responsible for any forms or payments left anywhere else.

6. Please keep your receipts for your records. Tax statements are available for an additional $5.00 per family or they may be emailed at no cost.

BREAK CREDITS 1. All payments made to the Boys & Girls Club of Truckee Meadows are final and non-refundable.

2. The only credit given is if the child is sick, is not at the club, and the parent calls by 9:00 A.M on the day of the field trip.

3. For any field trip that is cancelled either by the Boys & Girls Club or by that organization to which we are attending, the Boys & Girls Club reserves the right to relocate the destination with an equal or lesser value. We will give a notice to the parents and members when possible.

FIELD TRIPS 1. Some Field Trips may require that members bring water bottles, waivers, towels, sun block, extra clothes, helmets, etc.

2. Members are responsible for keeping track of these items and their use. No credit will be given for a lack of these items.

3. During Breaks, Reno sites are open Monday - Friday 7:00 A.M - 6:00 P.M and closed Saturdays and Sundays.

4. Fernley, during breaks, is open Monday – Friday 6:30 A.M – 6:00 P.M and closed Saturdays and Sundays.

5. Parents must pick up children ages 6 - 12 years from the Boys & Girls Club, NO LATER than 6:00 P.M.

6. Members may bring extra money for Field Trips. Members are responsible for their own money and prizes. We are not re-sponsible for lost or stolen money and prizes.

7. A field trip t-shirt is required for all specialty camps and field trips. Shirts cost $5.00 each. If your child has lost their t-shirt before the field trip they can buy a new one for $5.00. If they have just forgotten their t-shirt for that day they can rent a temporary t-shirt for $1.00 and rented t-shirts must be returned after the field trip that day. If the t-shirt is not returned, a $5.00 charge will be applied to the members account.

8. Parents / Guardians are NOT allowed to pick up or drop off members at ANY of the Field Trips.

LATE POLICY FOR BREAKS: THERE IS NO GRACE PERIOD AFTER CLOSING TIME

Parents must pick up children ages 6 - 12 years from the Boys & Girls Club, no later than 6 P.M. There is no grace period after 6:00 P.M. After 6:15 P.M we will enforce an automatic suspension from the Club with no credit given for missed field trips.

We reserve the right to call Reno Police Department (R.P.D.) and/or Child Protective Services (C.P.S.) as of 6:15 P.M if we are unable to reach an adult by phone.

03/2016 Building For The Future

This facility participates in the Child and Adult Care Food Program (CACFP), a Federal program that provides healthy meals and snacks to eligible children and adults. Each day 3.3 million children and 120,000 adults participate in the CACFP across the country. Providers are reimbursed for serving nutritious meals and snacks which meet USDA requirements. The CACFP plays a vital role in improving the quality of programs and making it more affordable for low-income families. Meals - CACFP meals and snacks must follow meal requirements established by USDA

Breakfast Lunch or Supper Snacks (Two of the four groups)

Milk Fruit or Vegeta-ble Grains or Bread

Milk Meat or meat alternate Grains or bread Two different servings of fruits or vegetables

Milk Meat or meat alternate Grains or bread Fruit or Vegetable

Participating Facilities – Many different programs operate CACFP and share the common goal of bringing nutritious meals and snacks to participants. Participating facilities include: Child Care Centers: Licensed or approved public or pr ivate nonprofit child care center s, Head Star t programs, and some

for-profit centers. Family Day Care Homes: Licensed or approved pr ivate homes. Afterschool Programs: Programs with learning and enr ichment activities in low-income areas that provide one free meal

and/or snack per day to school-age children and youth. Homeless Shelters: Emergency shelter s that provide meals to temporar ily displaced or homeless children and youth. Adult Day Care Centers: Licensed or approved public or pr ivate nonprofit adult care center s and some for -profit centers

which provide structured, comprehensive services. Eligibility – State agencies reimburse facilities that offer non-residential day care to the following: Children age 12 and under, Migrant children age 15 and younger, Children and youth through age 18 in emergency shelters or in afterschool programs in needy

areas, and Adults who are functionally impaired, or aged 60 or older.

Contact Information – If you have questions about CACFP, please contact one of the following:

Sponsoring Organization/Center State Agency

Sponsor Name Boys & Girls Club CACFP Nutrition Programs Professional Nevada Department of Agriculture, Food and Nutrition Division 2300 E. St. Louis Avenue Las Vegas, NV 89104-4211 (702) 668-4585

Address 2680 E. Ninth Street

Phone Number

775 331 5437

In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race, color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA. Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audi-otape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Addi-tionally, program information may be made available in languages other than English. To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Sub-mit your completed form or letter to USDA by: (1) mail: U.S. Department of Agriculture, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; or (3) email: pro-gram.intake@usda.gov.

This institution is an equal opportunity provider.

03/2016 Construyendo Para El Futuro

Esta facilidad participa en el programa de Cuidados de Alimentos para Niños y Adultos (CACFP), un programa Federal que propor-ciona alimentos y bocados saludables a niños y adultos elegibles. Cada día 3.3 millones de niños y 120,000 adultos toman parte en el programa CACFP a través del país. Los proveedores son reem-bolsados para servir alimentos y bocados nutritivos que siguen los requerimientos del USDA. El programa CACFP es esencial en mejorar la calidad de programas haciéndolo más asequible a familias de bajos ingresos.

Alimentos - Las comidas de CACFP y bocados deben seguir los requer imientos establecidos por el USDA. Desayuno Almuerzo o Comida Bocadillos (Dos de los cuatro grupos)

Leche Fruta o verdura Granos o pan

Leche Carne o un sustituto de carne Granos o pan Dos porciones diferentes de frutas o verduras

Leche Carne o un sustituto de carne Granos o pan Fruta o verdura

Facilidades Participantes – Muchos programas diferentes operan el programa CACFP y comparten el objetivo común de traer comi-das y bocados nutritivos a los participantes. Las facilidades o centros participantes incluyen: Centro de Cuidados de Niños: Los centros de cuidados de niños públicos, con licencia o los centros pr ivados no lucrativos,

el programa de Head Start, y algunos no-lucrativos Hogares de Cuidado de Niños: Hogares con licencia o pr ivados Programas Después de la Escuela: Programas que proporcionan aprendizaje y enr iquecedoras actividades que están ubi-

cadas en áreas de bajos ingresos que proporcionan por día gratis una comida y/o bocado a niños y jóvenes en edad escolar. Refugios para Personas sin Hogar: Refugios de emergencia que proporciona comidas a niños y jóvenes que han sido tem-

poralmente desplazados o están sin hogar. Centros de Cuidados de Adultos: Centros de cuidados con licencia o centros públicos aprobados o pr ivados no-lucrativos u

algunos centros lucrativos que proporcionan estructurados y completos servicios. Elegibilidad – Las agencias estatales reembolsan los gastos a los establecimientos que ofrecen servicios de cuidado no residencial a los siguientes: Niños de 12 años de edad o menores, Niños de familias migratorias de 15 años de edad o menores, Los niños y los jóvenes hasta la edad de 18 años que están en refugios de emergencia o en programas de

después de la escuela, y Adultos incapacitados o de 60 años de edad o mayores Para Más Información – Si tiene preguntas acerca del programa CACFP, por favor póngase en contacto con un de los siguientes:

Organización Patrocinadora/Centro Agencia Estatal

Nombre del Patrocinador Boys & Girls Club CACFP Cuidado de Alimentos para Niños y Adultos Nevada Departamento de Agricultura, División de Alimento y Nutrición 2300 E. St. Louis Avenue Las Vegas, NV 89104-4211 (702) 668-4585

Dirección 2680 E Ninth Street

Teléfono 775 331 5437

De conformidad con la Ley Federal de Derechos Civiles y los reglamentos y políticas de derechos civiles del Departamento de Agri-cultura de los EE. UU. (USDA, por sus siglas en inglés), se prohíbe que el USDA, sus agencias, oficinas, empleados e instituciones que participan o administran programas del USDA discriminen sobre la base de raza, color, nacionalidad, sexo, discapacidad, edad, o en represalia o venganza por actividades previas de derechos civiles en algún programa o actividad realizadas o financiadas por el USDA. Las personas con discapacidades que necesiten medios alternativos para la comunicación de la información del programa (por ejem-plo, sistema Braille, letras grandes, cintas de audio, lenguaje de señas americano, etc.), deben ponerse en contacto con la agencia (estatal o local) en la que solicitaron los beneficios. Las personas sordas, con dificultades de audición o discapacidades del habla pue-den comunicarse con el USDA por medio del Federal Relay Service [Servicio Federal de Retransmisión] al (800) 877-8339. Además, la información del programa se puede proporcionar en otros idiomas. Para presentar una denuncia de discriminación, complete el Formulario de Denuncia de Discriminación del Programa del USDA, (AD-3027) que está disponible en línea en: http://www.ascr.usda.gov/complaint_filing_cust.html y en cualquier oficina del USDA, o bien escriba una carta dirigida al USDA e incluya en la carta toda la información solicitada en el formulario. Para solicitar una copia del formulario de denuncia, llame al (866) 632-9992. Haga llegar su formulario lleno o carta al USDA por: (1) correo: U.S. Departamento of Agricultura, Office of the Assistant Secretary for Civil Rights, 1400 Independence Avenue, SW, Washington, D.C. 20250-9410; (2) fax: (202) 690-7442; o (3) correo electrónico: program.intake@usda.gov

Esta institución es un proveedor que ofrece igualdad de oportunidades.