Beat The Street Member Information Form
Are you an existing Beat The Street Member?
Yes
No
Enter Your Beat the Street Member Number
FOR EXISTING MEMBERS ONLY!
Which of the following programs are your interested in?
*
Boxing Fitness
Dance Program
Career Explorer
Live Sound Audio Engineering Program
Career Development Program
Community Garden
Participant's Name
*
First Name
Last Name
I am
*
Female
Male
Date of Birth
*
-
Month
-
Day
Year
Date
Your Address
*
Street Address
Street Address Line 2/ Apartment #
City (type the full name of the city)
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Best phone number to reach you at . (Start with area code)
Your Email Address
*
example@example.com
Race/Ethnicity - Select One
*
Hispanic
Hispanic + Black
Hispanic + Asian
Hispanic + American Indian
Hispanic + Pacific Islander
Other Hispanic
Black
White
Asian
American Indian
Pacific Islander
Multi-racial - Not Hispanic
Other - Not Hispanic
How did you find out about Beat The Street Community Center?
*
From a friend or relative
From an ad or flyer
From Social Media
Referral
Other
Do you have internet at home?
*
Yes
No
What School or College do you go to?
*
I don’t go to school or college
Meriden - Benjamin Franklin
Meriden - Hanover School
Meriden - Israel Putnam
Meriden - John Barry
Meriden - Lincoln Middle School
Meriden - Maloney High School
Meriden - Middlesex Community College
Meriden - Nathan Hale
Meriden - Platt High School
Meriden - Pulaski School
Meriden - Roger Sherman
Meriden - Thomas Edison
Meriden - Thomas Hooker
Meriden - Washington Middle School
Meriden - Wilcox Technical High School
Other
EMERGENCY CONTACT INFORMATION
If you are age 18 or younger, your emergency contact must be a parent or legal guardian.
1. Name of Emergency Contact
*
First Name
Last Name
Contact Relationship To You
*
Contact Email address, if they have one
example@example.com
Home Number
Work Telephone Number
Mobile Telephone Number
2. Name of Emergency Contact (Additional Contact) - OPTIONAL
First Name
Last Name
Contact Relationship to you
Contact Email address, if they have one
example@example.com
Home Number
Work Number
Mobile Telephone Number
Please provide as many contact phone numbers as possible. You must provide at lease one contact phone number
Contact CELL phone number. (Start with Area Code).
Please enter a valid phone number.
Contact HOME phone number. (Start with Area Code).
Please enter a valid phone number.
Contact WORK phone number. (Start with Area Code).
Please enter a valid phone number.
Voluntary Survey
Ethnicity:
American Indian
Asian
Black
Caucasian
Hispanic
Other
Number of Adults in Household:
Number of Children in Household:
Members of Household:
Married
Single
Single - Female Head of Household
Single - Male Head of Household
Grandparent/Relative/Guardian
Estimated Annual Gross Income:
Equal to or Less than $20,000
$20,001 to $35,000
$35,001 to $50,000
Greater than $50,000
Medical Information
Physician’s Name
First Name
Last Name
Name of Medical Practice
Telephone
“Beat The Street Community Center, Inc.” recommends that you receive a complete physical prior to participating in the physical activities offered by “Beat The Street Community Center, Inc.”
Is your physician aware that you are participating in a stretching, aerobic and/or weight training program?
*
Yes, My Physican has been notified
No, My Physician has not been notified
I choose note to answer
Do you have or had you ever had any of the following?
*
Heat problems (Heart Murmur, Heart Disease, etc.)
Mental disorders
Back problems
Arthritis
Mono
High Blood Pressure
Diabetes
Seizures
Bleeding Disorder
Fractured Bone/s
Respiratory problems
Difficulty with Exercise
Anemia
Hepatitis
Recent Surgery
Other Medical Conditions
No, I do not have any of the above Medical Conditions.
I choose note to answer
Please describe in detail if you answered yes to any of the above conditions:
Do you exercise 30 minutes for 3 or more times per week?
*
Yes
No
I choose note to answer
Please read the below information:
I understand that "Beat The Street Community Center, Inc." assume no responsibility for injuries or illness which I may sustain as a result of my physical condition or resulting from my participation in any athletic activity, sports program, exercise, and/or the use of any equipment at "Beat The Street Community Center, Inc.". I acknowledge on behalf of myself and my heirs that I assume the risk for any and all injuries and illness which may result from any participation in these activities. I hereby release and discharge "Beat The Street Community Center, Inc." its agents, servants and employees from any and all claims for injury, illness, loss or damage which I may suffer as a result of my participation in these activities. In an emergency, I authorize "Best The Street Community Center, Inc." to administer first aid by trained staff and to obtain medical treatment for any person list on this application. I understand that the Ambulance will be contacted for transportation to the nearest Medical Facility Emergency Room. I accept responsibility for all fees incurred in the care and transportation. By refusing to answer questions concern my health/child's health, I explicitly agree to absolve "Beat The Street Community Center, Inc." its officers, partners, agents or employees (releases) from any and all liability, loss, damage, cost or expense which "Beat The Street Community Center, Inc." and its releases incur. suffer or be required to pay if I am hurt, injured, fall ill by reason of my participation in any of the exercise activities or progress. I understand that "Beat The Street Community Center, Inc." is not responsible for personal property lost, damaged or stolen while members and/or program participants are using "Beat The Street Community Center, Inc." facilities or located on "Beat The Street Community Center, Inc." premises. I present to "Beat the Street Community Center, Inc." that the participant is in good physical condition and have no physical conditions that would prevent me from participating in exercise activities established by "Beat The Street Community Center, Inc.". I understand that no willful misconduct will be tolerated. Management has the right to terminate my privileges if I fail to adhere to the Rules and Regulations. I agree to indemnify and save harmless the said "Beat The Street Community Center, Inc.", its officers, patrons, agents or employees (releases) from any and all liability, loss, damage, cost or expense which "Beat The Street Community Center, Inc." And it releases may incur, suffer or be required to pay if I'm hurt, injured or fall ill by reason of my participation in any exercise activities. I give permission to "Beat The Street Community Center, Inc." to use, without limitation or obligation, photographs, film, footage, or tape recordings which may include my image or voice for promotion or interpretation of "Beat The Street Community Center, Inc." programs. As a member I understand that Beat the Street Community Center, Inc. policies and requirements maybe be updated periodically, and I agree to comply with all current and future versions of these policies and program and membership requirements.
I acknowledge and accept the policies set forth above and, being in alignment with the goals and purposes of "Beat The Street Community Center, Inc.", I hereby apply for membership.
*
By Signing below, I acknowledge that I have read and fully understand the above and have answered the said truthfully to the best of my knowledge. Particpant's Signature If age 18 or older AND Parent/Guardian Signature if Participant is under the age of eighteen (18):
*
Date
*
-
Month
-
Day
Year
Date
Continue
Continue
Should be Empty: