2022 Membership Application
1. Member Information
Name
*
First Name
Last Name
Date of Birth
*
January
February
March
April
May
June
July
August
September
October
November
December
Month
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Day
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
Gender
Male
Female
Other
Pronoun
Health Card Number (optional)
Address
Street No. Apt/Unit (If Applicable)
Street Address Line 2
City
Postal / Zip Code
Member E-mail Address
*
example@example.com
Member Cell Phone
Member Home Phone
We know that people of different races do not have significantly different genetics. However, our race still has important outcomes, including how we are treated by different individuals and institutions. Which race category best describes you? Check all that apply:
Black
Indigenous (First Nations, Métis, Inuk/Inuit)
East Asian
Southeast Asian
Latino
Middle Eastern
South Asian
White
Do Not Know
Prefer Not to Answer
Other
Language(s) spoken (please mark preferred)
Religion/Creed - please also list any holidays observed
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2. School Information
Member's School
Grade
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3. Family Information
Member resides with:
Both Parents
Father
Mother
Guardian
Mother/Father/Guardian
First Name
Last Name
Address
Same as Member
Other (provide details below)
Address
Street No. Apt/Unit (If Applicable)
Street Address Line 2
City
Postal / Zip Code
Home Phone Number
Same as Member
Other (provide details)
Home Phone
Work Phone
Cell Phone
Email
example@example.com
Mother/Father/Guardian
First Name
Last Name
Address
Same as Member
Other (provide details below)
Address
Street No. Apt/Unit (If Applicable)
Street Address Line 2
City
Postal / Zip Code
Home Phone Number
Same as Member
Other (provide details)
Home Phone
Work Phone
Cell Phone
Email
example@example.com
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4. Emergency Contact (Other than Parent/Guardian)
Name
First Name
Last Name
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Relationship to Member
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5. Boys & Girls Club Child Pick-up In/Out Privileges (Very Important Information)
Members 6 to 12 will not have in/out privileges at the Club. In order for them to leave the premises, a parent/guardian or someone (aged 13 years or older) authorized by the parent/guardian must pick them up. Please identify individuals who may pick up your child, including older siblings (13+)
Members aged 13 years or older will be allowed to leave the Club on their own provided that the parent/guardian has indicated below that the child has permission to do so (if safety is a concern the BGCO has a right to ask a parent to pick up the child.
I give permission for my child to have in/privileges at the Club, which includes walking home on their own
I do not give permission for my child to have in/privileges at the Club, which includes walking home on their own
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6. Additional Information
Does your child require additional support in any of the following areas?
Physical
Learning
Behavioural
If you have checked any boxed above, please explain further and list diagnosis where applicable
Does your child have any of the below conditions?
Attention Deficit Hyperactive Disorder
Asthma
Autism Spectrum Disorder
Epilepsy
Sensory Processing Disorder
Mood and/or Anxiety Disorder
Other
Comments:
Does your child have any allergies?
No
Yes (please complete the table below)
The Boys and Girls Club of Ottawa is fortunate to provide barrier-free programming due to our funders, can you please assist us in obtaining additional information about the children we serve. Do you consider your child to be included in any of the following groups? (check all that apply)
Immigrant/New Canadian
Military Family
2SLGBTQIA+
Rural Resident
Member of Visible Minority
Person with a Disability
I prefer not to answer
Not a member of these groups
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7. Parental Authorization: Your responses will help us maintain a barrier free, no cost program
My child may participate in surveys for program evaluation
Yes
No
Initials
My child may appear in photographs (printed material) used for reporting, publicity purposes and/or promotion of the BGCO
Yes
No
Initials
My child may appear in photographs (internet/media) used for reporting, publicity purposes and/or promotion of the BGCO
Yes
No
Initials
I, the undersigned, the parent or guardian, having applied to the BGCO ("the Club") on behalf of my child or ward for membership in the Club, and in consideration for acceptance by the Club of my application, do hereby give permission for my child or ward to participate in the Club and their programs including all scheduled outings, unless I advise in writing to the contrary. Having investigated the activities and resources of the Club to my satisfaction, I understand that due care and attention will be given to the safety of all participants including my child or ward, but that the Club, its leadership, managers, staff and volunteers cannot be held liable for any injury or loss, howsoever caused, and I release the Club, its ts leadership, managers, staff and volunteers on behalf of my child or ward, from any liability and from all claims arising, directly or indirectly, from participation by my child or ward in Club activities. I further understand that the Club reserves the right to remove my child or ward from the program if the Club deems it necessary to ensure the safety and well being of other participants
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