Mahomet Area Youth Club
Membership Enrollment Form
The MAYC membership year is from September 1 to August 31 and the annual membership fee is
$20.00. This membership is for year: September 1, 20____ to August 31, 20____.
Child’s Information
Child’s Full Name: _________________________________________ Nickname: ______________________
 Male
 Female
Birth Date: _____/_____/_____
Has he/she ever been enrolled in an after school program before?
Race: _________
Yes
No
Child’s interests:____________________________________________________________________________
Favorite Foods: ___________________________ Least Favorite Foods: ______________________________
Child feels uncomfortable when: ______________________________________________________________
Family Contact Information
Parents/Guardians: ___________________________________________________________________
Home Address: ______________________________________________________________________
City
State
Zip
___________________________________________________________________________________
Email
Home Phone
Cell Phone
Work
Authorized Individuals
Please list the name, address, phone number, and relationship for each person authorized to pick up your child under the age of 14 . No
child will be released to any individual not listed below or to any family or non-family member under the age of 18 . Any additions, deletions, modifications or request to list any family member authorized to pick up a MAYC member must be submitted in writing
by the parents and/or legal guardians.
1. ___________________________________________________________________________
Name
Address
Phone Number
Relationship
2. ____________________________________________________________________________
Name
Address
Phone Number
Relationship
3. ____________________________________________________________________________
Name
Address
Phone Number
Relationship
Youth and Family Information
MAYC collects and submits data to our funding and grant sources. Only the data is reported and no individual or family information is
released. Please complete the following information when submitting this form.
Head of Household: Single Parent Home Two Parent Home Foster Parent Relative Caregiver
Non-relative caregiver
Household Size:
Complete Family Size: ____
Number of Siblings_____
Number of Adults_____
Financial Assistance – check all that apply for every member of your household:
I/We do not receive Financial Assistance
TANF (Temporary Assistance for Needy Families) SSI or SSDI
Medical Card or KidCare WIC DCFS
Food Stamps
Free/Reduced Lunch
Annual Combined Household IncomeParents/Guardians: If you are seeking a reduced rate to qualify for reduced fees or a
MAYC Scholarship, you will be required to report any changes in household size, financial assistance received or income levels.
___Are you employed? Are there unemployed adults in the home? Yes No How Many: ______
0-4,999
5,000-9,999
10,000-19,000
20,000-29,000
30,000-39,999
40,000-49,999
50,000-59,999
60,000-69,000
70,000 and above
1 Mahomet Area Youth Club-Membership Enrollment Form
Medical and Emergency Contact Information
In the event of a medical emergency, MAYC staff will contact the parents immediately. If the person is suffering from a back, neck, head,
broken bone (arm or leg), or internal injury, MAYC Staff will call 911. ONLY THE PARENT/GUARDIAN WILL DIRECT STAFF NOT TO
CALL 911. If the parent/guardian cannot be reached, staff will contact the individual listed as the Emergency Contact Person.
Please list any health issues and/or problems:
_____________________________________________________________________
________________________________________________________________________________________________________________________
Child’s Doctor and Phone Number ____________________________________________________________
Child’s Medical Insurance Company: ________________ _ Policy Number/Medicaid Number: _____________
Emergency Contact Person Information
If there are any changes to the information provided below, please provide that information to MAYC.
___________________________________________________________________________________
Name
________________________
Address
__________________________
Home Phone
Relationship
________________________
Cell Phone
Work Phone
MAYC Agreements
MAYC offers several different activities that require that certain conditions, policies, rules and regulations be understood and adhered to by parents/guardians and our members. Please carefully review the following information
and if you permit your child to participate in and/or use the following MAYC resources, please sign and date the
space provided near each item.
MAYC Skate Park Agreement
1. Use of the MAYC Skate Park is for enrolled MAYC members only.
2. A parent/guardian must have a signed this portion of the MAYC Membership Application and MAYC Skate Park
agreement on file before using of the Skate Park.
3. The Skate Park is for skateboards only. No scooters or inline skates will be permitted in the skate park.
4. Helmets must be worn at all times while in the Skate Park.
5. Members are encouraged to have their own helmets. MAYC will provide a limited number of helmets for skate
park use.
6. All helmets must be worn in a safe manner.
7. Appropriate footwear (hard sole shoes) must be worn in the skate park.
8. Members are encouraged to supply and wear their own safety pads.
9. Skaters must exercise appropriate caution when younger or less experienced skaters are present, and must
respect the rights of all skaters.
10. MAYC members will be asked to clean and maintain the skate park prior and after use.
11. The MAYC Skate Park will not be open for use unless a MAYC staff member or qualified adult volunteer is
available to supervise the skate park activities.
12. The skate park will not be open after dusk.
13. Individuals who enter the skate park when the club is closed will be considered trespassing.
14. MAYC is not responsible for any members’ lost, stolen or broken equipment.
15. Should any MAYC members willfully or purposefully damage or destroy MAYC property, they will be asked to
reimburse MAYC for the actual replacement cost of any equipment or item damaged or destroyed.
16. MAYC will employ all reasonable effort to supervise and control activities conducted in the Skate Park to minimize the risk of injury, however, MAYC members use the Skate Park at their own risk. MAYC will not be
responsible for any injury or damage incurred while using the MAYC Skate Park.
 Approved by parent/guardian: ____________________________________
Signature of parent/guardian
 Not approved by parent/guardian. Access to the MAYC skate park is denied.
2 Mahomet Area Youth Club-Membership Enrollment Form
_____/_____/_____
Date
MAYC Computer Lab Agreement
1. Use of the MAYC Computer Lab is for enrolled MAYC members only.
2. A parent/guardian must have a signed this portion of the MAYC Membership Application prior to the MAYC
member using the computer lab.
3. No digital data, media, video or photographic material of any type will be downloaded to or from any computer or computer related equipment owned by the Mahomet Area Youth Club.
4. The Mahomet Area Youth Club will assume no control over sites visited nor assumes any responsibility for
the sites the member visits on the internet.
5. If the member visits any site of a controversial nature, including pornography, obscenity, excessive violence,
inflammatory and or dangerous nature and or material, the member may be suspended or expelled from the
Mahomet Area Youth Club.
6. No member is permitted to visit any type of social media page of any nature while at the Mahomet Area
Youth Club.
7. Should any member post any type of digital data (photographs, video, documents, etc.,) taken while at or
about the Mahomet Area Youth Club staff, members or volunteers without prior written approval, the member may be suspended or expelled from MAYC.
8. No inappropriate information will be exchanged, forwarded or shared with any Mahomet Area Youth Club
staff or MAYC members.
9. Members are responsible for the safe and appropriate use of MAYC computer equipment. If any member
damages or destroys any equipment, the family/guardian will be responsible for the cost of repair and or replacement.
 Approved by parent/guardian: ____________________________________
Signature of parent/guardian
_____/_____/_____
Date
 Not approved by parent/guardian. Access to the MAYC Computer Lab is denied.
MAYC Power House Agreement
1. Use of the MAYC Power House is for enrolled and paid MAYC members and individuals who have an approved waiver form.
2. All MAYC Members will be instructed on the appropriate use of all equipment. Members are to use equipment ONLY IF they understand how to use it correctly, preventing the risk of injury. Members must exercise
appropriate caution when using the equipment in the Power House.
3. MAYC members use the Power House at their own risk. MAYC does not assume any responsibility for any
injury sustained by any member utilizing the Power House.
4. Appropriate footwear (including socks) and clothing must be worn in the Power House at all times.
5. Athletic shoes must be clean in order to enter the Power House.
6. All weights and equipment must be put back and cleaned before exiting the Power House.
7. Members must leave the Power House in a clean and safe condition.
8. The Power House and Power House equipment are to be used for the intended purposes only.
9. The MAYC Power House will be available for use only when a MAYC staff member or qualified/approved
MAYC adult volunteer is available to supervise activities.
10. Parents/guardians are required to disclose any health or health related conditions of the member prior to use
of the Power House. MAYC will employ all reasonable effort to supervise and control activities conducted in
the Power House to minimize the risk of injury, however, MAYC members use the Power House at their own
risk. MAYC will not be responsible for any injury or damage incurred while using the MAYC Power House.
 Approved by parent/guardian: ____________________________________
Signature of parent/guardian
 Not approved by parent/guardian. Access to the MAYC Power House is denied.
3 Mahomet Area Youth Club-Membership Enrollment Form
_____/_____/_____
Date
Authorization
1. I give my consent for MAYC to release photographs in which my child appears to the media agencies and to
display or use photographs in promotional materials related to MAYC without any future monetary consideration or compensation.
2. To provide the best environment for my child and help strengthen my child’s positive involvement and success in school and non-school activities, I grant permission for MAYC to obtain copies of my child’s school
report card and share that information between any organization deemed appropriate by MAYC administration. Those agencies may include but not be limited to school districts, police departments, Scouting organizations, health services, etc.
3. I give permission for my child to be transported in a MAYC owned or operated vehicle for transportation to/
from home if applicable and on MAYC field trips.
4. I understand that no MAYC staff member may transport my child at any time in a privately owned vehicle.
5. I understand that MAYC cannot provide transportation for my child outside of MAYC authorized activities and/
or field trips.
6. I understand that my child must be signed out by myself or an authorized person as identified on the enrollment form. If my child is being transported home in a MAYC vehicle, a MAYC staff member must sign my
child out.
7. I understand that members aged fourteen (14) years or older may leave the club and he/she will not be permitted to come back to MAYC during same day without prior approval from a MAYC Administrative Staff person.
8. I understand and agree that the Mahomet Area Youth Club will not be held liable for my child if he/she leaves
MAYC facilities or an off-site activity of his/her own free will. I further agree that MAYC will not be held liable
if my child suffers an accidental injury while on MAYC property, or while engaged in a MAYC sponsored activity off-site.
9. I understand that if my child requires medication during after school program hours, a "Permission for Medications" form must be completed and information regarding dose and time of administration must be provided to
MAYC staff and that the medications will be kept in clearly labeled original containers. I understand that no
over the counter medications will be given such as Tylenol, cough liquid, etc. without written consent from my
child’s physician.
10. I have received and reviewed the Mahomet Area Youth Club Parent and Member Handbook with a MAYC
staff member.
11. I understand that the Mahomet Area Youth Club is not responsible for any lost, stolen, broken or misplaced
property.
12. I understand that if membership in the Mahomet Area Youth Club is terminated by either MAYC and/or myself, membership fees are not refundable.
I/we have read and agree to the policies, rules, regulations and conditions of this agreement and any document
referenced in the agreement.
_______________________________________________
Parent/Guardian Signature
______________
Date
_______________________________________________
Member Signature
______________
Date
_______________________________________________
MAYC Staff Member Signature
______________
Date
4 Mahomet Area Youth Club-Membership Enrollment Form