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
Sex *
Member living with *
 

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.

Contact Information

Emergency Information 

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

Notifications (optional)
Text Alerts
Newsletter
We are always looking for help for events and during Club, would you like to receive more information about volunteer opportunities with our Boys & Girls Club?
Best way to reach you
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. *
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