Western Avenue Membership Registration Form

Western Avenue Community Center Program Registration

Complete the form below to sign up for our Youth Programs
Which program are you registering for?
If you are registering for Youth Baseball and need to apply for a financial assistance to your child(ren) to participate please visit the following link:

https://www.bnba.net/Default.aspx?tabid=1102711

For other league information please don't hesitate to reach out to Coach T at
(309) 829-4807
PARTICIPANT NAME*

First NameLast Name
Birth Date:*

MonthDayYear
Age*
Gender*
Race*
School*
type n/a if not currently enrolled in any school
Grade (next school year)*
type n/a if not currently enrolled in any school
SECOND PARTICIPANT NAME

First NameLast Name
SECOND PARTICIPANT'S Birth Date:

MonthDayYear
SECOND PARTICIPANT's Age
SECOND PARTICIPANT's Race
SECOND PARTICIPANT's School
type n/a if not currently enrolled in any school
SECOND PARTICIPANT's Grade (next school year)
type n/a if not currently enrolled in any school
Method of transportation TO WBLP
Method of transportation FROM WBLP
WBLP T-Shirt Size (ALL are based on adult sizes)*
(Second Participant )WBLP T-Shirt Size (ALL are based on adult sizes)*
Please list any health conditions/concerns (if none type n/a)*
WACC does not apply or administer ANY medications to members. If you child(ren) takes medication, Please make arrangements with administrative staff prior to attending program
PARENT/GUARDIAN NAME or (Seniors repeat your name here)*

First NameLast Name
PARENT/GUARDIAN Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:*

Area CodePhone Number
E-mail Address*
This will be the PRIMARY form of communication Please list an email address that you use frequently
EMERGENCY CONTACT NAME*

First NameLast Name
EMERGENCY CONTACT Phone Number:*

Area CodePhone Number
APPROVED PICK UP LIST

Persons on this list must come in and show ID before member will be released to them
Name*

First NameLast Name
Name

First NameLast Name
Name

First NameLast Name
NO CONTACT NAME(S) (Please list anyone the member is NOT to have contact with)

First NameLast Name
NO CONTACT NAME(S) (Please list anyone the member is NOT to have contact with)

First NameLast Name
Membership Rules

Western Avenue reserves the right to change or modify these rules at any time
Members are expected to be respectful and courteous to staff of WACC and fellow members. Refusing to follow our rules and behavior guidelines may lead to suspension or immediate removal from our youth programs:
- Absolutely no physical or verbal altercations between fellow members or towards WACC Staff. Physical fighting, arguing, using offensive or vulgar language or any other behavior considered inappropriate will not be tolerated
- Cursing, Bullying, Gossiping, Acts or threats of violence and teasing members or WACC staff is NOT permitted and will result in IMMEDIATE REMOVAL from programming at WACC
- Please wear appropriate clothing. Items with curse words, vulgar language or pictures are NOT permitted. Members will be asked to leave if there are no alternate clothing options
- Ladies: please no crop tops that show your belly button, short shorts or revealing clothing of any kind
- Gentlemen: please keep your shirts on and no sagging pants
- During the Willie Brown Leadership Program we will be extremely active. For safety reasons tennis shoes MUST be worn EVERYDAY. Please NO CROCS open toed shoes, sandals, or slides
During the school year, transportation will be provided from Sheridan Bent & Irving schools to WACC. During summer months, you will be notified of the transportation method/schedule after registration. Members are NOT allowed to sign themselves out unless we receive prior notice or permission from parent/guardian. In the event that a member voluntarily leaves the premesis we will NOT chase or follow them instead all responsible parties will be notified. Otherwise, members will be released at to a responsible party at the end of programming.
Prior arrangements need to be made for members who walk or ride a bike to WACC.

Attendance at youth programming is not mandatory although we do encourage our members to attend all sessions to receive the all of the benefits of what the program offers. Please note, during the summer Willie Brown Leadership Program, members must attend at least two sessions Tues-Thurs to attend the field trip on Friday (Thursday is Mandatory) We understand that life happens and politely ask that if a member must miss a day of programming, please notify a member of WACC staff at your earliest opportunity.

We ask that participants of WACC programs treat all equipment, supplies, and within the facility properly and with care.

WACC is not responsible for any lost, stolen, or damaged items.

Partcipants shall not posess any objects that might be used or considered a weapon.

NO illegal items or substances allowed on the premesis including and not limited to drugs, alcohol, tobbaco, vapes or paraphernalia. No sexual language, gestures or conduct permitted.

Students are expected to partcipate in all activities they are registered for and cell phone usage will be monitored.
I have read, understood, and accepted the rules for membership.
Parent Permissions
I give my child permission to participate in programs at Western Avenue Community Center. I understand that my child’s partcipation in any recreational activities or programs at Western Avenue Community Center at my own risk. WACC is not liable for any injuries, or even death, that may occur to my child during partcipation
I have read, understood, and accepted the PARENT PERMISSION POLICY for membership.
LATE DROP OFF LATE PICK UP POLICY

Youth programming begings on time. Unless prior arrangements have been made any member arriving more than 30 minutes late, will not be permitted to participate that day. In the event that your child will be late, please notify a WACC staff member at the earliest opportunity

Youth programming ends on time (unless prior notification is given) Parents may begin picking up 15 minutes before the end time). In the event that you will arrive late, please notify a WACC staff member at the earliest opportunity. Five minutes after the program end time, WACC will charge parents $1/minute until picked up. If members have not been picked up 30 minutes after program end WACC will contact the local authorities. Late fees must be paid in full before member is allowed to return to programming
I have read, understood, and accepted the late drop off and late pick up policy for membership.
FIELD TRIPS
WACC staff will give parents/guardians information regarding scheduled field trips in advance. I give my child permission to participate in all scheduled (You will receive a permission slip) and/or impromptu outings (for example going to White Oak Park or to get ice cream) provided by Western Avenue Community Center. If students are NOT allowed to attend a field trip or outing, parent/guardians are responsible for finding alternative care for their child.

I understand that my child’s partcipation in any recreational activities or programs at Western Avenue Community Center is at my own risk. WACC is not liable for any injuries, or even death, that may occur to my child during partcipation. Parents/guardians will be informed of all field trips or outings prior to departure.
I have read, understood, and accepted the FIELD TRIP PERMISSION POLICY for membership.
PHOTO/VIDEOS/MEDIA: I am giving consent for photographs, videos and/or like materials in which myself, my son/daughter may appear, to be used in any of Western Avenue Community Center's (WACC) promotional, informational, or social media materials.
I have read, understood, and accepted the MEDIA POLICY for membership.
Should be Empty:

Western Avenue Community Center Program Registration

APPROVED PICK UP LIST

Membership Rules

Parent Permissions