Boys and Girls Club How To Join Print Form

of Poplar Bluff
Membership Application

To Be Completed By Club Staff: Member Number: _____________
New: _________ Renewal: _________ Fee Fully Paid: Yes / No

Membership fees: $20.00 per year

Name:__________________________________________________________________________________________

(First) (Middle) ( Last )

Date of Birth:___/____/____ Age:________ Sex: Male/Female # of Siblings: ____________

Address:________________________________________________________________________________________

(Street) (City) (State) (Zip)

Phone: (_______)_____________________________ Social Security Number: _______-_______-__________

School Child Attends: ______________________________ Grade: ___________________

Guardian Name: _________________________________ Guardian Name: _________________________________

Relationship: ___________________________________ Relationship: ____________________________________

Guardian Employer: _________________________________________ Phone: (_______)______________________

Father's Employer: __________________________________________ Phone: (_______)______________________

Please Provide us with 2 Emergency Contacts:

Name / Relationship: _________________________________________Phone: (_______)______________________

Person's authorized to take child from facility:

Name / Relationship: _________________________________________Phone: (_______)______________________

**It is the responsibility of the parent to notify us of any changes to this information.

For reporting purposes we would appreciate you filing out the following information:

With whom do you live: Both Parents_______Father_______Mother_______Other_______

Number of individuals living in home: _________________________

Family Annual Income:

$0 - $15,000______$15,000 - $30,000______$30,000 - $45,000______$45,000 - $60,000_______$60,000 - and over______

Ethnic Origin:

African American______Asian______Hispanic/Latino______Caucasin______Native American______Bi-Racial______

Other________________________

Can Member swim? _______Yes_______No

My child Does / Does Not have my permission to walk from the Boys and Girls Club facility.

The only way my child could attend is if they had transportation from the Boys and Girls Club of Poplar Bluff (Yes / No). If your child needs transportation home, would you be willing to pay $1.00 per day (Yes / No)?

I do / do not give my child permission to be interviewed, photographed, or video taped. I do / do not give consent for my child to be video taped, photographed, to participate in television reports, and newspaper articles concerning the Boys & Girls Club of the Poplar Buff Area.

Authorization for Emergency Medical Care: Does your child have any serious health problems? Yes / No

Explain?________________________________________________________________________________________

Medical problems / Allergies:________________________________________________________________________

Child Development / Special Needs: (List Allergies, special needs or other concerns)

_______________________________________________________________________________________________

The facility of preference for my child's health care concern is:______________________________________________

_____________________________Family Physician is:__________________________________________________

Please provide Insurance Information: _______Private Insurance_______Medicaid_______MC+_______Other

I understand that I will be notified at once in case of accident or illness to my child, and I will make arrangements for medical care for my child with the physician or hospital of my choice. If I cannot be reached to make necessary arrangements, or in a critical emergency requiring medical care, I hereby authorize the Boys & Girls Club of Poplar Bluff

Authorization for School Release

I give permission to Poplar Bluff R1 School District & Sacred Heart School to share all grade reports with the Boys & Girls Club of Poplar Bluff to further enhance my child's education. I give permission for Poplar Bluff R1 School District to release any information to the Boys & Girls Club of Poplar Bluff. I give permission for the Boys & Girls Club of Poplar Bluff to communicate with my child's teacher, view and copy grade reports and discuss strategies that will help my child to become a successful student.

Having been informed that the Boys & Girls Club of Poplar Bluff, provide supervised athletic, recreational, educational, cultural, and guidance programs for boys and girls, I, the applicant and I/We the Parent/Guardian of the below names candidate for membership in the Boys & Girls Club of Poplar Bluff do hereby agree, and give my/our consent for her/his participation in any and all the activities conducted by the Club while he/she is a member. In consideration of permission given to my child/children listed above by the Boys & Girls Club of Poplar Bluff, of Poplar Bluff Missouri to participate in all activities, I release and discharge the Boys & Girls Club of Poplar Bluff, its agents, employees, commissioners, and officers, from all claims, demand, actions,, judgments, and executions, which I ever had, or now have, or may have or which my heirs, personal representatives or assigns may have or claim to have against the Boys & Girls Club of Poplar Bluff, its successors or assigns for all personal injuries to my child listed below, known or unknown, and injuries to property, real or personal, caused by, arising out of, the activity or activities offered by the Boys & Girls Club of Poplar Bluff. I/We likewise release from responsibility any person transporting my/our child to or from all activities sponsored or conducted by the Boys & Girls Club of Poplar Bluff.

I have read this release and understand all its terms. I sign it voluntarily and with full knowledge of its significance. I consent to my child participating in all activities as stated above and assumed all risks.

Parent / Guardian Signature:________________________________________________Date:____________________

Signature of Applicant:_____________________________________________________Date:____________________