Request for membership

*Please read all information and print responses.
*Before membership is made official, the parent/guardian must meet with a designated Club staff

member to review these forms and have any outstanding questions answered.
*It is the parent’s responsibility to notify Club staff of changes to the following information.
*Additional registration may be required for special programming (e.g. field trips, all-day programs).

Club Member Information

Name

First

Middle

Last

Date of Birth

Sex

Male

Female

Mailing address

Physical address (if different than mailing)

Home Phone

Mobile Phone

School

Grade (2022-2023)

Club Member/Family Notes (i.e. allergies, asthma, emotional/behavioral concerns, court order, family/custody status): Information provided is confidential. For your child’s safety and success at Club, this portion must be completed.

Alert/Note

Treatment/Response/Additional Info

Alert/Note

Treatment/Response/Additional Info

Alert/Note

Treatment/Response/Additional Info

Contact Information

Parent/Guardian Name

Relationship to child

Home Phone

Mobile Phone

Occupation

Place Of Employment

Email Address

Parent/Guardian Name

Relationship to child

Home Phone

Mobile Phone

Occupation

Place Of Employment

Email Address

Emergency Information

Contact (not guardian)

Allergies

Relationship to child

Medications

Contact Phone Number

Health Ins. Carrier

Pick up Information

Only listed individuals (other than those already listed above) will be allowed to pick up the club member. Any edits to this list can only be made by the legal guardian:

Name

Relationship to member

Name

Relationship to member

Name

Relationship to member

Name

Relationship to member

I give my permission for medical emergency treatment of my child for illness or accident; if I cannot be contacted.

Notifications (optional)

Text Alerts

Name

Mobile phone with texting

Newsletter

Name

Email address

We are always looking for help for events and during Club hours. Would you like to receive more information about volunteer opportunities with our Boys & Girls Club?

Yes

Name

Time available

Interest

Best way to reach you

Phone Number

By checking this box, I am indicating that I will request a copy of the parent/club member handbook and am responsible for reviewing it with my club member.

Agree