Boys & Girls Club Membership Registration - Epuerto Sports - Soccer, Track and Field, Basketball, Volleyball, Teqball

Product Name

How many children do you want to register?*

Enter children's names

1st participant name*

Date of Birth*

School*

Grade*

Gender*

Male
Female

2nd participant name*

Date of Birth*

School*

Grade*

Gender*

Male
Female

3rd participant name*

Date of Birth*

School*

Grade*

Gender*

Male
Female

4th participant name*

Date of Birth*

School*

Grade*

Gender*

Male
Female

5th participant name*

Date of Birth*

School*

Grade*

Gender*

Male
Female

6th participant name*

Date of Birth*

School*

Grade*

Gender*

Male
Female

Parent/ Guardian Contact Information

Father’s Name*

First Last

Employer

Cell #*

Work #

Military*

Yes
No

Start Date

Branch

Mother’s Name*

First Last

Employer

Cell #*

Work #

Military*

Yes
No

Start Date

Branch

Email & Home Address

**Please enter your address to receive program and registration updates by Email

Email*

Street Address*

Street Address City ZIP Code

Member Lives With

Other than parent, Emergency Contact Person

Name

First Last

Relationship to Member

Phone #

Home
Cell
Work

Medical Data

Does child have any special needs?

Family Doctor Name

Doctor Phone

Does your child have any food allergies?

Yes
No

Please list all medication s your child is taking and any medical problems/allergies

PERSON(S) NOT AUTHORIZED TO CONTACT MEMBER

Please note that legal documentation must be presented

Name

Description

GREAT FUTURES START HERE

This information will be kept in strict confidence. This information is important because it makes the Boys & Girls Club eligible to receive various grant funding. It also helps us to identify members who qualify for FREE eye care including eye exam and glasses.

Family Size*

Single Individual
Family of 2
Family of 3
Family of 4
Family of 5
Family of 6
Family of 7
Family of 8
Family of 9 or more

Family Income*

$ 0 to 29,920
$ 29,921 to 34,160
$ 34,160 to 38,400
$ 38,401 to 42,640
$ 42,641 to 46,080
$ 46,081 to 49,520
$ 49,521 to 52,880
$ 52,881 to 56,320
$ 56,321 or more

Family Ethnicity*

White
American Indian / Alaskan Native
Two or More Races
Black / African American
Hispanic / Latino
Native Hawaiian / Pacific Islander
Asian
Other Race

Is your family eligible or signed up for Free/ Reduced lunch at your child’s school?*

Yes
No

Please agree for approval or mark N/A:

I have read the completed application; understand the rules of the Boys & Girls Club of Southwestern Oregon (BGCSWO) and request that my son/daughter be admitted into membership. I have explained the rules to my son/daughter and we understand that my child’s members status is based upon his/ her ability to obey the rules of the BGCSWO and behavior toward the staff members and volunteers. Memberships may be suspended or terminated at any time for misbehavior without a refund.*

Agree
N/A

I agree that BGCSWO will not be responsible for any accident to my son/daughter while on the premises or while engaged in any Club activities away from BGCSWO. I also give my consent to allow my child to be treated by a physician or hospital in the event of an emergency, and to his/her being transported to and from the necessary destination. I will not hold the members of the Board, Staff, Volunteers or Sponsors responsible for any injury that may occur while participating in any BGCSWO activities or programs.*

Agree
N/A

I further grant the Boys & Girls Club and the news media, in any form, permission to publish/use photographs or videotaped footage of my son/daughter for any purpose relating to the Boys & Girls Club and release the Boys & Girls Club and any news media of responsibility from the use of such photographs or footage.*

Agree
N/A

I agree that if my son or daughter needs to be picked up due to illness, injury or suspension, I will pick up my child or arrange to have him/her picked up within 30 minutes. Plus, I understand that my child must be picked up before the Club closes, and that the BGCSWO is not responsible for supervising members after closure times. A late fee will be enforced if a child is not picked up before closing time.*

Agree
N/A

I understand that the Club, its employees and agents, shall not be responsible for any losses of personal property.*

Agree
N/A

I hereby give permission for the Boys & Girls Club to have access to my child’s/ teens teachers, grades and/or report cards in conjunction with programs related to education. I may revoke this authorization at any time by notifying the BGCSWO in writing, how ever it will not affect any actions taken before the revocation was received or actions taken based on previously shared info.*

Agree
N/A

I hereby grant my consent for my child to participate in surveys or other program evaluation mechanisms instituted by the BGCSWO. I understand all results will be kept strictly confidential.*

Agree
N/A

I have received a Parent Handbook and agree to all rules and requirements of Boys & Girls Club membership.*

Agree
N/A

OPEN DOOR POLICY In keeping with Boys & Girls Club policy across the country our drop-in program operates with an open door policy. The decision regarding when the child leaves the Club, and with whom, is strictly between parent and child.

Total

$0.00

Signature*