Membership Application

Membership Application

GOLDSBORO 919-735-2358 | FREMONT 919-242-3276 | MOUNT OLIVE 919-658-9836
Date

MonthDayYear
Date
Application Type

RENEWALNEW
Please note that at this time our Goldsboro and Mt. Olive locations are at capacity. All applications to this location are currently going to a wait list.
Club:*
MEMBER (CHILD) INFORMATION:
MEMBER #:
For renewals only
Child's Name:*

First NameLast Name
Date of Birth:*

MonthDayYear
Date
A copy of a Birth Certificate is required for all six (6) year old children. Please upload here. If you do not want to upload here, you may bring a copy in to be attached to the file.

Browse Files

Cancelof
Did you upload a birth certificate file?*

YesNo, Will bring one in.No, Child is not 6 years old
Gender*
Shirt Size
Anticipated Start Date:*

MonthDayYear
Date
Child Lives with:*

Both ParentsMother OnlyFather OnlyGrandparent(s)Step-MotherStep-FatherFoster FamilyOther
If living with Foster Family, please list name and phone # of Case Worker:
Are you a Military Family?*

YesNo
If Yes, branch?

ArmyAir ForceNavyMarinesCoast Guard
Does your child receive:*

Free LunchReduced LunchNeither
When will your child attend the Club?*

School YearSummer OnlyAll YearSports OnlySpecial Program
Has your child previously belonged to a Boys & Girls Club?*

YesNo
If Yes, previously attended location/city?
Total # of years as a Club member?
PARENT/GUARDIAN CONTACT INFORMATION:

Contact #1
First Parents Name:*

First NameLast Name
Relationship to child:*
Address:*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone:
Work Phone:
Cell Phone:*
Email:
example@example.com
Employer:*
Primary Contact for billing?*

YesNo
PARENT/GUARDIAN CONTACT INFORMATION:

Contact #2
Second Parents Name:

First NameLast Name
Relationship to child:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone:
Work Phone:
Cell Phone:
Email:
example@example.com
Employer:
Primary Contact for billing?

YesNo
CUSTODY INFORMATION:
Are there any custody issues the staff should be made aware of?*

YesNo
If yes please attach any official court documents regarding custody that requires the Clubs to limit a child’s contact with a parent, custodial or non-custodial. These documents MUST be provided to the Clubs or we cannot enforce. You may also bring them to the club if you wish.
Custody Document Upload

Browse Files

Cancelof
EMERGENCY CONTACT: #1

Whom can be contacted if the parent/guardian cannot be reached
First Emergency Contact*

First NameLast Name
Relationship to child:*
Home Phone:*
Work Phone:
Cell Phone:
Allowed to pick up child if parent cannot be reached?*

YesNo
EMERGENCY CONTACT: #2

Whom can be contacted if the parent/guardian cannot be reached
Second Emergency Contact

First NameLast Name
Relationship to child:
Home Phone:
Work Phone:
Cell Phone:
Allowed to pick up child if parent cannot be reached?

YesNo
MEDICAL INFORMATION:

Including Allergies, Medications, and Special Needs
Please list any allergies we should be aware of. Please check all that apply:*

NonePollenDustMoldDogsCatsBeesPeanutsLatexDiaryTree NutsOther
Please list all medical concerns and medications:*

NoneAsthmaADD/ADHDAutismDiabetesEczemaEpilepsyGastrointestinalOther
Medications*

Other
Please list AND describe any special needs or special classifications (IEP, 504, etc.) your child may have:*
If none, please type none or N/A
Doctor’s Name:*
Doctor's Practice*
Doctor's Phone*
Insurance?*

MedicaidOther Health InsuranceAccident Insurance
Insurance Provider*
If no insurance please type None
Policy Number:
TRANSPORTATION:

Whom can pick up your child(ren)
How will your child be transported home at the end of program?*

Picked-Up via CarWalk Home
Are there any persons you would like to authorize to pick up your child, other than the parents and emergency contacts? If so how many?
1 to 5 more persons may be selected.
Person #1's Full Name:
Person #1's Phone Number:
Person #1's Address:
Person #1's Relationship to Child:
Person #2's Full Name:
Person #2's Phone Number:
Person #2's Address:
Person #2's Relationship to Child:
Person #3's Full Name:
Person #3's Phone Number:
Person #3's Address:
Person #3's Relationship to Child:
Person #4's Full Name:
Person #4's Phone Number:
Person #4's Address:
Person #4's Relationship to Child:
Person #5's Full Name:
Person #5's Phone Number:
Person #5's Address:
Person #5's Relationship to Child:
SCHOOL INFORMATION:
Name of School:*
Grade:*
Homeroom Teacher:*
If not in High School, please list teachers name.
Current GPA:*
If unknown type 0
Which extracurricular activities/programs is your child active in?*

BandChoirSportsYMCA4-HMath / Science ClubRobotics ClubGirl ScoutsBoy ScoutsOther
DEMOGRAPHIC INFORMATION:

(For statistical purposes only. Used to secure grants!)
Ethnicity:*

African AmericanCaucasianHispanicMulti-RacialAsianCaribbean IslandsNative AmericanPacific IslanderOther
Housing:*

RentOwnPublic HousingFoster CareShelterOther
Annual Household Income:*

Below $7,500$7,501 - $15,000$15,001 - $30,000$30,001 - $50,000Above $50,001
Total number of individuals who live in the household:*
How many siblings?*
Were you referred to the Boys & Girls Club? (Check all that apply)*

Parent / GuardianSchoolLaw EnforcementClergyCommunity ShelterBGC MemberDepartment of Social ServicesMental Health ServicesJuvenile CourtN/A (Not Applicable)Other
BOYS & GIRLS CLUBS “SAFE PASSAGE” POLICY:
Boys & Girls Clubs has a ‘Safe Passage’ policy, which allows Club members to come and go as their parent/guardian sees fit. A parent/guardian may request in writing each time their child leaves the Club or is signed out by an adult. A parent/guardian may allow a member to sign themselves out, this would be a member self-sign out request. This gives the

member the ability to sign themselves out of the Club. Boys & Girls Clubs staff will make reasonable efforts to ensure that only members with an adult signed member self-sign out permission leaves unaccompanied.

IT IS THE RESPONSIBILITY OF THE PARENT/GUARDIAN TO INFORM THE MEMBER OF EXPECTATIONS RELATIVE TO REMAINING AT THE CLUB UNTIL SIGNED-OUT OR PICKED UP BY A DESIGNATED PERSON. MEMBERS WHO LEAVE THE CLUB IN VIOLATION OF A WRITTEN MEMBER SELF-SIGN OUT REQUEST MAY BE SUBJECT TO SUSPENSION FROM THE CLUB.

Please check the option that fits your wishes:
Please check the option that fits your wishes:*

I request that my child is signed out by an adult. (Adult MUST come in to sign the child out)I formally grant permission to my child to sign themselves out. (Applies ONLY to members aged 14 and up.)
Parent / Guardian (Print)*
Please type in your full name as you would sign it
Signature*

Clear
Please use your mouse or finger to sign your name as you would on any other legal document
Date

MonthDayYear
Date
PARENTAL RELEASE FORM:

Please read this in its entirety
Liability Clause: I, the parent/guardian of the minor child listed on this applications, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Clubs of Wayne County, Inc.

(hereinafter known as BGCWC) and Boys & Girls Clubs of America (hereinafter known as BGCA), their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club. I understand that BGCWC shall not be responsible or legally liable for any bodily injuries or the result thereof incurred and suffered by my child on any property of BGCWC, or while engaged in any activity away from the club, unless such loss or injury results directly from negligence or willful act or any employee of BGCWC acting within the scope of his/her employment.

Medical Consent: I give consent to BGCWC to seek emergency medical treatment for my minor child if I cannot be reached. I consent that my child may be transported and given medical treatment if it becomes needed. I will be responsible for any cost of medical attention and treatment incurred. I give BGCWC consent to use over-the-counter topical ointments, sunscreen and topically applied insect repellant.

School Information: I give consent to BGCWC, Wayne County Public Schools (WCPS) and any private/charter schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to better help the member be successful in school, in the Boys & Girls Clubs and in life. This release is valid for one year and may be revoked at any time by contacting BGCWC in writing.

Survey/Questionnaires: I give consent for BGCWC to survey my child about his/her Club experiences, behaviors, skills, and attitudes using BGCA’s National Youth Outcome Survey or other instruments such as pre/post testing pertaining to Boys & Girls Clubs programs. Example of programs: Power HOUR, SMART Moves, Triple Play, Healthy Habits, etc.

Technology: As a member of BGCWC, your child will have access to the Internet. While precautions are taken at the Club to secure and protect all members, it is possible s/he may access inappropriate sites. BGCWC has rules and consequences at the Clubs for such behavior; however, we will not be responsible for the consequences of such access.

Bring Your Own Device (BYOD): We allow members to use the Wi-Fi in our facility. The same precautions on our wired network are used to secure and protect the children while using the Wi-Fi. However, if a child is not on the Wi-Fi those precautions are not in effect. We cannot control what your child does on his/her data plan, if applicable. If your child is seen accessing inappropriate content, your child will be required to turn their device into the front desk and will remain there till a parent/guardian picks up the child.

Media Release: I give consent for my child’s photo, video, graphic depiction, or likeness used in media published in BGCWC advertisements, publications, press releases, or used in conjunctions with partner agencies

Mentoring: I give consent to BGCWC to provide mentor programs/opportunities via BGCA if available.

Privacy: I give consent to BGCWC to share information about my child with BGCA and other grant funders, for research purposes to evaluate the programs’ effectiveness. Information that will be disclosed to BGCA may include information provided on this membership application form, information proved by my child’s school and/or school district, surveys or questionnaires, and other data collected by BGCWC. All information collected or provided to BGCA and other grant funders will be kept confidential.

Miscellaneous: I understand the Club is not, nor does it claim to be, a licensed day care center. I understand membership st ends December 31 of each year. Parents and Club members are responsible for their own transportation to and from the Club. I understand the Boys & Girls Clubs is not responsible for lost or stolen items.
By checking this box, I agree to uphold the rules and regulations of Boys & Girls Clubs of Wayne County, Inc. as outlined in the Parent/Guardian Handbook, which was made available to me at the time of registration, and is always available at bgcwayne.org*

I Agree
Parent / Guardian (Print)*
Please type in your full name as you would sign it
Member's Name (Print)*
By typing in the members name, you are confirming that you have reviewed the above policy with them.
Signature*

Clear
By signing this
Date

MonthDayYear
Date

Should be Empty:

Membership Application

MEMBER (CHILD) INFORMATION:

PARENT/GUARDIAN CONTACT INFORMATION:

PARENT/GUARDIAN CONTACT INFORMATION:

CUSTODY INFORMATION:

EMERGENCY CONTACT: #1

EMERGENCY CONTACT: #2

MEDICAL INFORMATION:

TRANSPORTATION:

SCHOOL INFORMATION:

DEMOGRAPHIC INFORMATION:

BOYS & GIRLS CLUBS “SAFE PASSAGE” POLICY:

PARENTAL RELEASE FORM:

Credit Card