For Office Use Only
Staff Initials: ____
Mem. # ________
Date: ________
Activity Card: 6 months-7 years ($30) Membership Card: 8 -18 ($40)
Please PRINT all information and answer all questions. Only complete forms will be
processed. All information provided remains confidential and is used for both safety
and funding purposes, to keep costs affordable.
MEMBER INFORMATION
First Name: _____________________ Last Name: _____________________
Date of Birth: _____/_____/____
Gender: ________________________
Street Address: ____________________________ Apt./Suite:____ __
City, State: __________________
___ Zip:
Home #: _________________
SCHOOL INFORMATION
School Name: _____________________ Grade Level: _____________________
MEDICAL INFORMATION
Allergies: _____________________ Explain any medical, physical, or social
challenges: ___________________________________________________________
PARENT/GUARDIAN INFORMATION #1
Name: ____________
_________ Relationship to Member: _________________
E-Mail: ______________
_________ Phone: ________________________
EMERGENCY CONTACT INFORMATION (For the rare case in which parents are unable to
be reached during emergency)
Name: _____________
________
Relationship to Member: ___________________
E-Mail: ________
__
_____________
Phone: ________________________
How did you hear about
us?
□
Facebook
□ Flyer
□ Club Member
(name)_________________
□Other___________
DEMOGRAPHIC INFORMATION
Household Income:
Ethnicity
Foster
Child?
Child of
Military?
□ African American □ Asian
□0-$25,000
DEMOGRAPHIC INFORMATION
□Yes
□Yes
□$25,001-$50,000
□No
□No
□$50,001-$75,000
Single Parent?
□Hispanic/Latino
□$75,001-$100,000+
□White
□ Two or more
races
□American Indian
□Yes
□No
□Other___________
PARENT/GUARDIAN CONSENT/RELEASE FORM (Please initial after each statement)
I do hereby give my son/daughter permission to attend and participate in activities
sponsored by the Boys & Girls Club. I hereby release the Boys & Girls Club, its employees,
associates and contributors from liability from any injury, loss or theft incurred by my
son/daughter while participating. Furthermore, I hereby authorize medical examination
and emergency treatment for my son/daughter by a qualified licensed physician in the
event of an accident. I understand that the costs for such treatment will be my
responsibility. X___
My Child has permission to be used in public relation materials for the Boys & Girls Club
of Greater Billerica. Examples of these include photographs, videos, and web pages.
X___
I understand that my child will have access to the internet while at the Club and that
he/she will be instructed on the proper use of a computer, including appropriate
websites X___
I understand that the Drop-in program is not a licensed childcare facility and that it
maintains an OPEN-DOOR policy. This means that if a child were to leave the building,
they are not allowed to come back in. X___
Member Signature:________
__________________________
Parent/Guardian Signature:_____
Date:______________________
_____________________