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Member Information

First Name*
Middle Name
Last Name*
Birth Date*
Age*
Gender
School*
Grade*
	current school year
Address*
City*
State*
Zip*
Member Status*
Which Club Are You Applying For?*
Ethnicity*

Ethnicity Other

Member Lives With*

Member Lives With Other

Number of family members in househould*

Parent/Guardian

Parent/Guardian Who Member Lives With

First Name*

Last Name*

Address*

City*

State*

Zip*

Employer

Job Title

Home Phone

Work Phone

Cell Phone

Other Parent/Guardian

First Name

Last Name

Address

City

State

Zip

Employer

Job Title

Home Phone

Work Phone

Cell Phone

Household Demographics

The following information is necessary for our records and the funding our organization recieves. The answers you provide are completely confidential. Your cooperation in providing this information is appreciated.

Other Programs Your Household Participates In*

TANF	Day Care Voucher	School Lunch
SSDI	WIC	General Assistance
SSI	Food Stamps	Veterans Compensation

Annual Household Income*

Medical Information

Basic Information
Insurance Company or Medical Assistance Program
Insurance Policy Number
Medical Problems, Allergies, Disabilities
Medications
Preferred Hospital or Clinic
Physician
Physician Phone
Emergency Contacts
Please list names that are not listed previously on this form
Contact #1
Name*
Phone*
Relation to member*
Contact #2
Name*
Phone*
Relation to member*

Permissions

Computer Usage

Members at the Boys & Girls Club of Grand Rapids Youth Commonwealth have access to filtered internet in our computer lab in order to do research, work on school projects, as well as to access to games and other websites. Our computers are equipped with internet filters and our lab is supervised by an adult at all times.

Do you give your child permission to use Club computers?

Yes

Media Release

The Boys & Girls Club of Grand Rapids Youth Commonwealth has my authority to use photographs, videos, reproductions, and any sound recordings of my child. Such use may include advertisements and publicity purposes.

Do you grant such permissions?

Yes

Medical Consent to Treatment

I the undersigned parent(s) or guardian of minor named above, minro do hereby consent to an x-ray examination, anesthetic, medical or surgical treatment, diagnostic procedure or service that may be rendered to said minor under the general or specific instructions of emergency department physician from emergency medical facility or other physician rendering emergency care. It is understood that this consent is given in advance of any specific diagnosis or treatment being rendered, but is given total consent to emergency treatment as may be needed. I hereby release and agree to hold harmless the Boys & Girls Club of the Grand Rapids Youth Commonwealth, its employees, agents, and/or affiliates from and against any claim for injuries or damage that might arise out of our child�s participation in the program. This consent will continue in effect for all who may rely upon it including, but not limited to the medical facility and physician on its medical staff and the Boys & Girls Club of the Grand Rapids Youth Commonwealth, until expiration date, unless they have received written notice of revocation.

Do you consent to the medical treatment of said minor as outlined above?

Yes

Club Policy Consent

I understand that the Boys & Girls Club of the Grand Rapids Youth Commonwealth does not take my responsibility for lost, missing, or damaged items. It is recommended that personal belongings be left at home and all bikes are properly locked in the designated area.
I understand that the Boys & Girls Club of the Grand Rapids Youth Commonwealth reserves the right to suspend my child from Club activities if my child exhibits poor behaviors. It is my responsibility to meet with the Unit Director or Site Supervisor to discuss any matter of concern on either the Boys & Girls Club part or mine.
Club hours of operation are established for each program site. Failure to arrange timely transportation for my child to and from Club property may result in a service charge.
I understand the Club is closed on the following holidays or their recognized day: New Years Day, Memorial Day, 4th of July, Labor Day, Thanksgiving Day, Christmas Eve, and Christmas Day and from time to time other days which will be posted in advance.
I understand that if my child is in the 1st�5th grade I am required to attend a parent orientation before my child can become a member and receive his or her card.
I understand that the Boys & Girls Club of the Grand Rapids Youth Commonwealth operates their Club sites with an open door policy. 1st�5th grade members are not allowed to leave the building unless going home for the day. Members in the 6th�12th grade are allowed to leave the building.

Do you give your child permission to leave the Club unattended?

Yes

Do you give your child permission to walk/bike home?

Yes

Membership Fee & Electronic Signature

The current membership fee is $5.00 a year. Membership is September 1 — August 31, and memberships are not active until this payment is recieved at the Club which your child will be attending.

Do you understand your child will not be a member until after this fee is paid?

Yes

I verify under penalty of law that I am the parent/guardian of fore mentioned minor and that I have answered all questions contained in this form truthfully, and to the best of my ability.

Yes

Name of person signing this form*

Dated

5-19-2012

Our Mission

To enhance the character of youth through recreation, education and other positive experiences in partnership with the Grand Rapids Police Department.