Member Information Update Form

STUDENT INFORMATION UPDATE FORM

School Site

Todays Date

Date

Childs Name

First NameLast Name

Grade

Information Update: Complete all fields that need to be updated.

Pick Option that needs an Update

Photos or videos may be taken of my child and used for marketing and training purposes.

My child may have access to the Internet while in the program.

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Home Phone Number

Format: (000) 000-0000.

Cellphone Number

Please enter a valid phone number.Format: (000) 000-0000.

Authorized Pickup Name

Phone Number

Format: (000) 000-0000.

Relationship to child

Authorized Pickup Name

Phone Number

Format: (000) 000-0000.

Relationship to child

Authorized Pickup Name

Phone Number

Format: (000) 000-0000.

Relationship to child

Authorized Pickup Name

Phone Number

Format: (000) 000-0000.

Relationship to child

Email

example@example.com

Name

Signature

This program is made possible through a partnership between Garden Grove Unified School District and Boys & Girls Clubs of Garden Grove.

Please complete ONLY the portions that need to be updated. When you finish, skip any parts you do not need and sign at the bottom.