Pickleball Membership Price: $1 for 1 Month Player's Name:* Player's Name is Required Phone: Phone is not valid Shirt Size:* Shirt Size is Required YSYMYLASAMALAXL Grade:* Grade is Required Pre KK1st2nd3rd4th5th6th7th8th9th10th11th12th Parent/ Guardian Contact Information Father’s Name:* Father’s Name is Required Father’s Employer: Father’s Employer is not valid Father’s Cell #: Father’s Cell # is not valid Father’s Work #: Father’s Work # is not valid Father is Military?: Father is Military? is not valid Yes No Mother’s Name: Mother’s Name is not valid Mother’s Employer: Mother’s Employer is not valid Mother’s Cell #: Mother’s Cell # is not valid Mother’s Work #: Mother’s Work # is not valid Mother is Military?: Mother is Military? is not valid Yes No Email & Home Address **Please enter your address to receive program and registration updates by Email Email:* Email is Required Street Address:* Street Address is Required City:* City is Required Zip Code:* Zip Code is Required Member Lives With:* Member Lives With is Required Both Parents Mother ONLY Father ONLY Parent & step parent Foster Parent Joint Custody Other Other than parent, Emergency Contact Person Other Contact Person Name: Other Contact Person Name is not valid Other Contact Person Relationship to Member: Other Contact Person Relationship to Member is not valid Other Contact Person Phone #: Other Contact Person Phone # is not valid Medical Data Does child have any special needs?: Does child have any special needs? is not valid Asthma Diabetes Seizures Migraines ADHD/ADD Other Needs Family Doctor Name: Family Doctor Name is not valid Doctor Phone: Doctor Phone is not valid Does your child have any food allergies?: Does your child have any food allergies? is not valid Yes No Please list all medication s your child is taking and any medical problems/allergies: Please list all medication s your child is taking and any medical problems/allergies is not valid Person(s) not Authorized to Contact Member Person(s) not Authorized to Contact Member Name: Person(s) not Authorized to Contact Member Name is not valid Person(s) not Authorized to Contact Member Description: Person(s) not Authorized to Contact Member Description is not valid 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:* Family Size is Required Single IndividualFamily of 2Family of 3Family of 4Family of 5Family of 6Family of 7Family of 8Family of 9 or more Family Income:* Family Income is Required $ 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:* Family Ethnicity is Required WhiteAmerican Indian / Alaskan NativeTwo or More RacesBlack / African AmericanHispanic / LatinoNative Hawaiian / Pacific IslanderAsianOther Race Is your family eligible or signed up for Free/ Reduced lunch at your child’s school?:* Is your family eligible or signed up for Free/ Reduced lunch at your child’s school? is Required 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.:* 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. is Required 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.:* 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. is Required 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.:* 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. is Required 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.:* 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. is Required Agree N/A I understand that the Club, its employees and agents, shall not be responsible for any losses of personal property.:* I understand that the Club, its employees and agents, shall not be responsible for any losses of personal property. is Required 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.:* 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. is Required 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.:* 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. is Required Agree N/A I have received a Parent Handbook and agree to all rules and requirements of Boys & Girls Club membership.:* I have received a Parent Handbook and agree to all rules and requirements of Boys & Girls Club membership. is Required 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. Date of Birth: Date of Birth is not valid Gender: Gender is not valid Male Female School Presently Enrolled: School Presently Enrolled is not valid If enrolled in Middle School/Jr.-Hi, Last Elementary School Attended: If enrolled in Middle School/Jr.-Hi, Last Elementary School Attended is not valid Username:* Invalid Username Email:* Invalid Email Password:* Invalid Password Password Confirmation:* Password Confirmation Doesn't Match Have a coupon? Coupon Code: Invalid Coupon Coupon applied successfully No val Please fix the errors above TSAOClaserGAT2025-01-20T08:54:23-08:00
