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| Saturday, September 04, 2010 |
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Membership Application
Boys & Girls Clubs of Sanford/Lee County
NO REFUNDS
Unit Name:_____________________________ Date______________
First Name: _____________ Middle: _____________Last:_______________
Nickname: _________________ Gender: M ______ F ______ Race:__________
DOB: __________________________ SSN: _________________________
Address:___________________________________________________________________________
City: _________________ Zip:__________Phone:_____________________
School Information:
Current Teacher: _________________________ Lunch: (Please Circle One) Free Reduced Full
School: ______________________________ Grade: _________________
Medical Information:
Doctor Name: __________________________Doctor Phone: ____________
Permission for Treatment by Doctor/Hospital: ___Yes ____ No Medicaid: ____ Yes ____No
Does your family have health and/or accident insurance: ____Yes ______ No
Insurance Carrier: ______________________________________________
Policy #: ____________________________ Group #: __________________
Date Health Info Received: __________________________
Serious Health Problems: _____ Yes _____No If Yes,explain ____________
Medications: ______ Yes ______ No If Yes, explain: ___________________
General:
Birth Certificate on File: ____Yes ____No Birth City: __________
Birth State: ___________
Member/Contacts understood signed insurance declaimer and permission statement:
______ Yes ______ No
Member has permission to be used in public relations materials:
_____ Yes ______ No
Member may participate in all Club activities in or adjacent to the club building: ______ Yes ______ No
Club Member Since: __________ Religion: __________
Household: (Note: This information is collected for grant writing purposes only)
Member lives with: ____ Mom _____ Step Mom ____ Dad _____Step Dad ____ Grandparent _____ Other: ________
Number in Household: ______________
Is there a member of the household 65 years or older: _____ Yes ______ No
Is there a member of the household handicapped: _____ Yes _______ No
Current Head of household: ______ Female ______ Male
Current Single Parent: _____ Yes _____ No
Physical:
Eye Color: _________ Hair Color: ___________ Skin Color/Features: ______
Height: ______________ Weight: _______________
Do You Belong to Other Groups:
______Boys Scouts or Girl Scouts__School Club __YMCA __Church Group
______ Other: _______________________
Reason(s) for joining: ______Fun ______Learning ______Sports ____ Other: _______________
Disclaimer:
I _____________________ do hereby give my son/daughter ______________________________ permission to attend and participate in activities sponsored by the Boys & Girls Clubs of Sanford/Lee C. I hereby release the Boys & Girls Club, it's employees, associates, and contributors from liability from any injury, loss or theft incurred by my son/daughter by a qualified licensed physician in the event of an accident. I further understand that the Boys & Girls Clubs of Sanford/Lee Coiunty has an "Open Door" policy, which means that my son/daughter may come and go at will. Further I give permission for my child's picture to be used in any Boys & Girls Club publication. My signature indicates that I completely understand the above statement.
Guardians Signature: ______________ Members Signature: ______________
For Office Use Only: Membership #: ________________
Entry Date: ______________ Expiration Date: ______________
Status: _________________
Type: ____________New/Renewasl Member: ____________
Processed by: ________________
Contacts/Pick Up List:
Primary Contact:
Relationship to Member: __________________________
Person Authorized to pick up Member: _______________
Name: _______________________
Phone: _______________________ Type: ___________
Employer: _____________________________________
Phone: _______________________ Type: ___________ Relationship to Member: __________________________
Person Authorized to pick up Member: _______________
Name: _______________________
Phone: _______________________ Type: ___________
Employer: _____________________________________
Phone: _______________________ Type: ___________
Relationship to Member: __________________________
Person Authorized to pick up Member: _______________
Name: _______________________
Phone: _______________________ Type: ___________
Employer: _____________________________________
Phone: _______________________ Type: ___________
Relationship to Member: __________________________
Person Authorized to pick up Member: _______________
Name: _______________________
Phone: _______________________ Type: ___________
Employer: _____________________________________
Phone: _______________________ Type: ___________
Relationship to Member: __________________________
Person Authorized to pick up Member: _______________
Name: _______________________
Phone: _______________________ Type: ___________
Employer: _____________________________________
Phone: _______________________ Type: ___________ |
