BGC Virtual Application

MEMBERSHIP APPLICATION 2024-2025

STUDENT DEMOGRAPHICS AND SCHOOL INFORMATION **Information requested supports data for various grants and(or) funding that supports BGCCC programming and will not be shared with 3rd party entities**
Student Grade Fall 2024*
School*
SSN #*
Student Name*

First NameLast Name
Gender*
Race / Ethnicity*
Date of Birth*

MonthDayYear
Student Email*
example@example.com
Student Cell #

Area CodePhone Number
Parent #1 Name*

First NameLast Name
Parent #1 Phone Number*

Area CodePhone Number
Parent #1 Employment Info*
Parent #2 Name

First NameLast Name
Parent #2 Phone Number

Area CodePhone Number
Parent #2 Employment Info
Mailing Address*

Street Address

Street Address Line 2

CityState

Zip Code
Single Parent Household ? *
Number in Household*
Including Parent(s)
Parent #1 Email*
example@example.com
Parent #2 Email
example@example.com
By checking the following, permission is given for for the following

My child has my permission to be used in public relations materials.My child has my permission to participate in Club activitites.
Signature*

Clear
FOR OFFICE USE ONLY
Membership Number
Expiration Date
Status
Renewal / New Member
Processed By:
Should be Empty: