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Boys & Girls Clubs of Central New Mexico - 2023 Summer Program Registration
For club membership during the 2023 summer programat 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, i.e: middle schoolers must attend middle school programs. Incoming freshman may attend middle or high school programs. ONLY SELECT ONE
*
Bernalillo - Elementary Program at Bernalillo Elementary School
Bernalillo - Elementary Program at Santo Domingo School
Bernalillo - Teen Program at Santo Domingo School
Albuquerque - Elementary Program at Adobe Acres Elementary
Albuquerque - Teen Program at Jimmy Carter Middle School
Albuquerque - Teen Program at Grant Middle School
Albuquerque - Teen Program at Highland High School (The HUB)
State ID - Student's 9-digit State ID can be found on ParentVue
*
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
Name of Member's Physician
*
Phone Number of Physician
*
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 1 - MUST BE DIFFERENT THAN PARENT/GUARDIAN
*
First Name
Last Name
Emergency Contact 1 Relationship to Member
*
Emergency Contact 1 Phone Number
*
-
Area Code
Phone Number
Is this emergency contact authorized to pick up member?
*
Yes
No
Emergency Contact 2 - MUST BE DIFFERENT THAN PARENT/GUARDIAN AND EMERGENCY CONTACT 1
*
First Name
Last Name
Emergency Contact 2 Relationship to Member
*
Emergency Contact 2 Phone Number
*
-
Area Code
Phone Number
Is this emergency contact authorized to pick up member?
*
Yes
No
Is member authorized to sign themselves out?
*
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 are responsible for their own transportation to and from the Club, unless otherwise specified. *Note: Bernalillo sites are the only sites that provide transportation.
*
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
Submit
Should be Empty: