MEMBERSHIP APPLICATION

MEMBERSHIP APPLICATION
SELECT MEMBERSHIP SITE:
PERSONAL INFORMATION
PARTICIPANT NAME:

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number

Area CodePhone Number
DATE OF BIRTH:

MonthDayYear
Date
GENDER:
1. PARENT/GUARDIAN NAME:

First NameLast Name
PHONE:

Area CodePhone Number
2. PARENT/GUARDIAN NAME:

First NameLast Name
PHONE:

Area CodePhone Number
I GIVE THE BOYS & GIRLS CLUB OF NIAGARA PERMISSION TO CONTACT US BY EMAIL:
EMAIL:
example@example.com
IS THERE A CUSTODY ARRANGEMENT WE SHOULD BE AWARE OF?
IF YES, PLEASE EXPLAIN:
FIRST EMERGENCY CONTACT (not listed above as PARENT/GUARDIAN):

First NameLast Name
RELATION:
PHONE:

Area CodePhone Number
SECOND EMERGENCY CONTACT (not listed above as PARENT/GUARDIAN):

First NameLast Name
RELATION:
PHONE:

Area CodePhone Number
PERMISSIONS & WAIVERS
Do you have any special requirements we should be aware of?
My child has permission to use club transportation.
My child has permission to leave the club WITH staff supervision.
My child has permission to leave the club UNSUPERVISED.
I consent to the collection, use and disclosure of my personal information during the course of my or my child's membership/services for the purpose set out in the Boys and Girls club of Niagara Privacy Policy
I consent to my child's image and picture being published in Web or digital material for publicity produced by the Boys and Girls Club of Niagara and/or its Branches.
I consent to my child`s participation in the Boys and Girls Club of Niagara programs.
YOUR SIGNATURE BELOW INDICATES YOU HAVE FULLY READ, UNDERSTOOD AND COMPLETED THE MEMBERSHIP FORM AND AGREE TO ALL PERMISSIONS AND WAIVERS CONTAINED HEREIN.
PARENT/GUARDIAN SIGNATURE:
DATE:

MonthDayYear
Date
Should be Empty:

MEMBERSHIP APPLICATION

PERSONAL INFORMATION

PERMISSIONS & WAIVERS