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:

YesNo
EMAIL:
example@example.com
IS THERE A CUSTODY ARRANGEMENT WE SHOULD BE AWARE OF?*

YesNo
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?*

Yes (an additional form will be provided after submission)No
My child has permission to use club transportation.*

Yes (Camp, Zones, Licensed Care)No
My child has permission to leave the club WITH staff supervision.*

Yes (Camp, Zones, Licensed Care)No
My child has permission to leave the club UNSUPERVISED.*

YesNo
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*

YesNo
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.*

YesNo
I consent to my child`s participation in the Boys and Girls Club of Niagara programs.*

YesNo
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:*

Clear
DATE:*

MonthDayYear
Date
Should be Empty:

MEMBERSHIP APPLICATION

PERSONAL INFORMATION

PERMISSIONS & WAIVERS