Boys & Girls Clubs of Central New Mexico - School Year 2022/2023 Membership Registration

Boys & Girls Clubs of Central New Mexico - School Year 2022/2023 Membership Registration

For club membership during the 2022/2023 school year at all sites. PLEASE FILL OUT SEPARATE FORMS FOR EACH MEMBER.
Today's Date *

Month Day Year
Date
Student / Member Name - please fill out separate forms for each member *

First Name Last Name
Nickname/Preferred Name
Club Location - Member's age/grade level MUST match their club location *

Albuquerque - Adobe Acres Elementary Albuquerque - Grant Middle School Albuquerque - Harrison Middle School Albuquerque - Jimmy Carter Middle School Albuquerque - Kennedy Middle School Albuquerque - Van Buren Middle School Albuquerque - Washington Middle School Albuquerque - Wilson Middle School Albuquerque - Highland High School (The HUB) Albuquerque - Del Norte High School Bernalillo - Algodones Elementary School Bernalillo - Bernalillo Elementary School Bernalillo - Cochiti Elementary School Bernalillo - Santo Domingo Elementary School Bernalillo - Placitas Elementary School Bernalillo - W.D. Carroll Elementary School Rio Rancho - Eagle Ridge Middle School Rio Rancho - Lincoln Middle School Rio Rancho - Mountain View Middle School
What school is member attending in the 2022/2023 school year? *

Albuquerque - Adobe Acres Elementary Albuquerque - Grant Middle School Albuquerque - Harrison Middle School Albuquerque - Jimmy Carter Middle School Albuquerque - Kennedy middle School Albuquerque - Van Buren Middle School Albuquerque - Washington Middle School Albuquerque - Wilson Middle School Albuquerque - Del Norte High School Albuquerque - Highland High School Bernalillo - Algodones Elementary School Bernalillo - Bernalillo Elementary School Bernalillo - Cochiti Elementary School Bernalillo - Santo Domingo Elementary School Bernalillo - Placitas Elementary School Bernalillo - W.D. Carroll Elementary School Rio Rancho - Eagle Ridge Middle School Rio Rancho - Mountain View Middle School Rio Rancho - Lincoln Middle School Other - Please Note: We DO NOT provide transportation to or from club locations. Members who wish to attend a club at a location where they do not attend school must get permission from the principal and coordinate with the club's site director. Members MAY NOT attend a club if they are not in the proper grade level - i.e. a 4th grader CANNOT attend a middle school club.
Type of Membership *

New Member Returning Member
Member Date of Birth *

Month Day Year
Date
Member Gender *

Male Trans Male Female Trans Female Non-Binary Other Prefer Not to Say
Member Race / Ethnic Identity *

American Indian or Alaskan Native Vietnamese Tibetan Asian Cape Veridian Jamaican Black or African America Middle Eastern or North African Native Hawaiian or Pacific Islander Puerto Rican Colombian Brazilian Hispanic or Latino White Multi Racial Other Prefer not to say
Is Member in Foster Care? *

Yes No
Member's Grade in 2022/2023 School Year - GRADE MUST MATCH CLUB LOCATION *

Kindergarten 1st 2nd 3rd 4th 5th 6th 7th 8th 9th (Freshman) 10th (Sophomore) 11th (Junior) 12th (Senior)
Does member receive additional support from their school or community? *

Yes - IEP (Individualized Education Plan) Yes - 504 Accommodation Yes - Speech Coach Yes - Meets with school or private counselor No
Food Allergies *

Peanuts Tree Nuts Dairy Lactose/Dairy Soy Gluten Seafood/Shellfish Eggs None
Medicinal Allergies *

Penicillin Aspirin Amoxicillin None
Environmental Allergies *

Bee Stings Pollen Dust Mold Grass None
Other Allergies *

Latex Perfume Lotions None
Medical Conditions *

Athsma Diabetes Hearing Impairment Blindness ADHD Autism Seizures Anxiety/Depression None
Does Member Use an Inhaler? *

Yes No
Does Member Use Insulin? *

Yes No
Does Member Self-Administer Medication? *

Yes No
If member self-administers medication, please list medication and dosage below:
To help us better serve you, please note any physical, mental, or medicinal limitations member may have below AND discuss with Site Director before first day:
Has member ever threatened or intentionally caused harm to themselves or others? *

Yes No
If yes, please explain:
Head of Household relationship to member (ex: Mother, Father, Foster Parent, Grandparent, etc.) *
Head of Household Name *

First Name Last Name
Head of Household Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Head of Household Primary Phone Number *

Area Code Phone Number
Head of Household Email
example@example.com
Head of Household Employer
Parent/Guardian 2

First Name Last Name
Parent/Guardian 2 Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Parent/Guardian 2 Phone Number

Area Code Phone Number
Parent/Guardian 2 Email
example@example.com
Is Parent/Guardian 2 authorized to pick up member?

Yes No
Emergency Contact *

First Name Last Name
Emergency Contact Relationship to Member *
Emergency Contact Phone Number *

Area Code Phone Number
Is the emergency contact authorized to pick up member? *

Yes No
Is member authorized to walk home? *

Yes No
Please list any tribal affilliations:
School Lunch Type *

Free or Reduced Entire School is Free Not Eligible
Please list any military affiliations (branch, status, ID number)
Please choose which assistance programs you recieve: *

Food Stamps/SNAP Medicaid Social Security SSI SSDI Housing (Section 7, Section 8, etc.) N/A
How many adults live in your household? *
How many children live in your household? *
Housing Type *

Permanant (rent, own, etc.) Group Home Foster Home Public Housing
Does member primarily live in a single-parent household? *

Yes No
Please indicate your annual household income (ex: $48,000): This information is used to determine financial aid eligibility and is for reporting purposes only. *
I give my permission to the BGCCNM to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, BGCA, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members. This release may be revoked at any time by contacting the BGCCNM in writing. *

Yes No
Medical: I give permission to the BGCCNM to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. *

Yes No
Transportation: I understand that Parents and Club members may be responsible for their own transportation to and from the Club, unless otherwise specified. *

Yes No
Data Sharing: I give my permission to the BGCCNM to share information about the minor child listed on this application with BGCA for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by BGCCNM, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential. This release may be revoked at any time by contacting the BGCCNM in writing. *

Yes No
Press: I give permission for my child’s picture, video image, or any other graphic depiction or likeness, to be used by BGCCNM, Boys & Girls Clubs of America and its affiliates or donors and acknowledge neither my child nor I will receive payment for same. *

Yes No
Miscellaneous: I understand that the Boys & Girls Club is not responsible for lost or stolen items. Each Club has the right to make membership decisions based on the resources and capacity of their facility and staff. BGCCNM reserves the right to decline the application, rescind the enrollment of, or suspend any youth that cannot successfully associate with other club members *

Yes No
I, the parent/guardian of the minor child listed on this application, on behalf of the minor child listed herein and for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Clubs of Central New Mexico (BGCCNM) and Boys & Girls Clubs of America (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 ClubYesNo *

Yes No
Please review the following Behavior Matrix:
I have reviewed the document above and understand the Behavior Matrix: *

Yes
Should be Empty: