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*

MonthDayYear
Date
Student / Member Name - please fill out separate forms for each member*

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

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

Albuquerque - Adobe Acres ElementaryAlbuquerque - Navajo ElementaryAlbuquerque - Valle Vista ElementaryAlbuquerque - Grant Middle SchoolAlbuquerque - Harrison Middle SchoolAlbuquerque - Jimmy Carter Middle SchoolAlbuquerque - Kennedy middle SchoolAlbuquerque - Van Buren Middle SchoolAlbuquerque - Washington Middle SchoolAlbuquerque - Wilson Middle SchoolAlbuquerque - Del Norte High SchoolAlbuquerque - Highland High SchoolBernalillo - Algodones Elementary SchoolBernalillo - Bernalillo Elementary SchoolBernalillo - Cochiti Elementary SchoolBernalillo - Santo Domingo Elementary SchoolBernalillo - Placitas Elementary SchoolBernalillo - W.D. Carroll Elementary SchoolRio Rancho - Eagle Ridge Middle SchoolRio Rancho - Mountain View Middle SchoolRio Rancho - Lincoln Middle SchoolOther - 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 MemberReturning Member
Member Date of Birth*

MonthDayYear
Date
Member Gender*

MaleTrans MaleFemaleTrans FemaleNon-BinaryOtherPrefer Not to Say
Member Race / Ethnic Identity*

American Indian or Alaskan NativeVietnameseTibetanAsianCape VeridianJamaicanBlack or African AmericaMiddle Eastern or North AfricanNative Hawaiian or Pacific IslanderPuerto RicanColombianBrazilianHispanic or LatinoWhiteMulti RacialOtherPrefer not to say
Is Member in Foster Care?*

YesNo
Member's Grade in 2022/2023 School Year - GRADE MUST MATCH CLUB LOCATION*

Kindergarten1st2nd3rd4th5th6th7th8th9th (Freshman)10th (Sophomore)11th (Junior)12th (Senior)
Does member receive additional support from their school or community?*

Yes - IEP (Individualized Education Plan)Yes - 504 AccommodationYes - Speech CoachYes - Meets with school or private counselorNo
Name of Member's Physician*
Phone Number of Physician*
Food Allergies*

PeanutsTree NutsDairyLactose/DairySoyGlutenSeafood/ShellfishEggsNone
Medicinal Allergies*

PenicillinAspirinAmoxicillinNone
Environmental Allergies*

Bee StingsPollenDustMoldGrassNone
Other Allergies*

LatexPerfumeLotionsNone
Medical Conditions*

AthsmaDiabetesHearing ImpairmentBlindnessADHDAutismSeizuresAnxiety/DepressionNone
Does Member Use an Inhaler?*

YesNo
Does Member Use Insulin?*

YesNo
Does Member Self-Administer Medication?*

YesNo
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?*

YesNo
If yes, please explain:
Head of Household relationship to member (ex: Mother, Father, Foster Parent, Grandparent, etc.)*
Head of Household Name*

First NameLast Name
Head of Household Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Head of Household Primary Phone Number*

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

First NameLast Name
Parent/Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2 Phone Number

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

YesNo
Emergency Contact - MUST BE DIFFERENT THAN PARENT/GUARDIAN*

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

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

YesNo
Is member authorized to sign themselves out?*

YesNo
Please list any tribal affilliations:
School Lunch Type*

Free or ReducedEntire School is FreeNot Eligible
Please list any military affiliations (branch, status, ID number)
Please choose which assistance programs you recieve:*

Food Stamps/SNAPMedicaidSocial SecuritySSISSDIHousing (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 HomeFoster HomePublic Housing
Does member primarily live in a single-parent household?*

YesNo
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.*

YesNo
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.*

YesNo
Transportation: I understand that Parents and Club members may be responsible for their own transportation to and from the Club, unless otherwise specified.*

YesNo
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.*

YesNo
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.*

YesNo
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*

YesNo
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*

YesNo
Please review the following Behavior Matrix:
I have reviewed the document above and understand the Behavior Matrix:*

Yes
Should be Empty: