Club Membership Form

For your child's well-being, the information you provide must be complete and accurate. This information is necessary to maintain funding, state compliance and records for Mor Girls With Goals. .The membership form will NOT be accepted without all forms completed and additional items received. Please check off each box below as you complete each section.

PROGRAM ATTENDANCE REQUIREMENTS

MGWG Programs/Events will benefit your child with regular attendance. If your child will be absent please notify . Excessive Absences (excused and unexcused ) may be grounds for dismissal from the program.

Members must be in attendance for all monthly meetings and required to attend community service events. With the exception for academics, illness, and prior engagements
Parents must be present to all parent required events

Checklist Items:

Membership ApplicationCopy of Most Recent Report Card

Attach Report Card

First Name

Middle

Last Name

Nickname

Age

Birthday

Date

Email

example@example.com

Address

City

State

Zip

Home Phone #:

Please enter a valid phone number.

Cell Phone #

Please enter a valid phone number.

Emergency Phone #

Please enter a valid phone number.

Name of School

Grade

Can member swim ?

YesNo

Are you a previous member of More Girls With Goals?

YesNo

Extracurricular(optional)

Mother's Name

Mother' Email

example@example.com

Cell #

Please enter a valid phone number.

Father's Name

Father's Email

example@example.com

Cell #

Please enter a valid phone number.

Name or Guardian (if different from mother or father)

Relationship To Guardian

Email

example@example.com

Cell #

Please enter a valid phone number.

Emergency Contact Name

Relationship

Emergeney Contact Phone Number

Email

example@example.com

List additional people to pick up your Child

Is Parent Active Military?

YesNo

Please Indicate Any Medical Problems, Allergies and/or behavior problems that may affect the staff or members of Mor Girls With Goals

Please Indicate Any Medication Presently Taking

Physical or Mental Limitations

Annual Household Income:

Number Of Brothers/Step Brothers

Number Of Sisters/Step Sisters

Number of Family Members in the Household

Check all that Apply

Child Family Setting:

Household Dwellings:

ApartmentHouseMobile HomeOther

I, the parent/guardian of the minor child listed on this application, for ourselves. our heirs, executors and administrators, hereby release, waive, acquit and forever discharge Mor Girls With Goals Inc their representatives, successors, insurers, assigns or any other person or entity associated with the organization 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 ownedor controlled by the above organization, or participation in activities of said organization either at or away.

Medical Treatment

I ,give permission to the Mor Girls With Goals Inc to seek emergency medical treatment for my minor child if cannot be reached. I will be responsible for any/all costs of medical attention and treatment.

Data Collection

I give my permission to the Mor Girls With Goals Inc 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, Mor Girls With Goals Inc, funders, and other community stakeholders to evidence program effectiveness and/or organization impact on our members.

School Information

I give my permission to Mor Girls With Goals Inc and {nameOf}School District to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Mor Girls With Goals and in life.

Data Sharing

I understand that the Mor Girls With Goals Inc may share information about the minor child listed on this application for research purposes and/or to evaluate the program's effectiveness. Information that will be disclosed to MGWG 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 Mor Girls With Goals Inc. including data collected via surveys or questionnaires. All information provided to MGWG will be kept confidential.

Miscellaneous

I understand that the Mor Girls With Goals Inc is not responsible for lost or stolen items. I give permission for my child's picture. moving pictures, or any other graphic depiction or likeness, to be used by Morg Girls With Goals Inc and its activities. I have read the completed application and this form, understand the rules of the Mor Girls With Goals Inc and request that my child be admitted into membership.

I give my permission to the Mor Girls With Goals Inc to share information about the minor child listed on this application for research purposes and/or to evaluate the program's effectiveness. Information that will be disclosed to MGWG 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 byMor Girls With Goals Inc including data collected via surveys or questionnaires. All information provided to MGWG will be kept confidential.

Parent / Guardian Signature

Club Member's Signature

Date

For office use only:

Date enrolled

Date

NewRenew

Staff Initials

Club Membership Form

Race/Ethnicity (optional)

School Information

General Information

Family History

Medical Information

Confidential Information: