REGISTRATION
Registration is a 2-step process, which only has to be done once. If you change your contact information, please let us know and we can update our system. Step 1: Fill out and submit this form. Step 2: You will be contacted by our Administrative Assistant to collect documentation that may be missing and answer general questions.
MEMBER'S INFORMATION
Member's Name
*
Last Name
Age
*
Date of Birth
*
-
Month
-
Day
Year
Date
Tribe(s)
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
School District
*
School
*
Grade
*
Does your child have any behavioral issues or disability issues that the Clubhouse staff should be aware of? (anxiety, insecurities, autism, ADHD, etc.)
How does your child prefer to be identified?
*
Female
Male
Other
CONTACT INFORMATION
Primary Parent/Guardian
*
First Name
Last Name
Phone Number
*
Please enter a valid phone number.
Email
*
example@example.com
Relationship to youth
*
Secondary Contact
*
First Name
Last Name
Phone Number for Secondary Contact
*
Please enter a valid phone number.
MEDICAL INFORMATION
Physician/Health Care Provider
Health Care Provider Phone Number
Please enter a valid phone number.
Health Care Provider Policy Number
Is your child allergic to any kind of food, plants, or medication?
*
No
Yes
Is yes, please list the allergy and describe their reaction and recommended pre-cautions and treatment.
Is your child currently on any medications?
Does your child experience motion sickness, Yes or No?
*
CODE OF CONDUCT
The Boys and Girls Club of UAII is a youth-serving, community-based organization dedicated to providing a safe and respectful environment. Participation in our Club activities is subject to the observance of the Club rules and procedures. The activities outlined below are strictly prohibited. Any participant who violates this Code is subject to suspension, or removal from the program. • Abusive language or rudeness towards a staff member, volunteer or another participant. • Possession or use of alcoholic beverages or illegal drugs on UAII property or checking-in while under the influence of drugs or alcohol. • Bringing onto UAII’s property dangerous or unauthorized materials such as explosives, firearms, weapons or other similar items. • Verbal, physical or visual harassment of another participant, staff member or volunteer. • Actual or threatened violence toward any individual or group. • Conduct endangering the life, safety, health or well-being of others. • Failure to follow any agency policy or procedure. • Bullying or taking unfair advantage of any participant. • Failing to cooperate with an adult supervisor/leader/mentor. I have read and I understand the Club Code of Conduct. I agree to abide by the rules described above and understand that I may be suspended, or removed, as a participant if I violate any of these rules.
PERMISSION TO PHOTOGRAPH/VIDEO AND PUBLICIZE
I hereby give permission to the American Indian Clubhouse to photograph my minor child at United American Indian Involvement, Inc. (UAII) events or at events the Club attends. I understand that photographs or videos of them, or their drawings and writing may appear in newspapers, magazines, television, video presentations, UAII publications and website, and social media applications. I agree that I will not demand payment of any kind in the event that my child’s picture, video, voice, likeness, drawings or writings are used by UAII to promote or publicize any of its programs or activities.
Signature
Today's Date
*
-
Month
-
Day
Year
Date
Please upload a current picture of the youth (face only)
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