Parent/Guardian Permission for Teen Membership

Parent/Guardian Permission for Teen Membership

This form needs to be completed for all teen youth enrolling themselves in a Boys & Girls Club Teen Membership on the Parent Portal via MyClubHub.
Teen Member Information
Teen Name*

First NameLast Name
Teen Date of Birth*

MonthDayYear
Date
Teen Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Household & Demographic Information

To keep our teen programs low- or no-cost, we apply for grants and funding that ask us to describe who we serve—as a whole. Your responses help us tell that story and bring more resources to our community.All answers are confidential and shared only in summary form.
Member Lives with: *
Housing Type: *
Number of Adults in Household*
Number of Youth in Household*
Primary Language Spoken at Home*
Household Income Range*
Allergies

We ask about allergies and dietary restrictions to ensure your teen’s safety and well-being while they participate in our programs. Whether it’s for daily snacks, special events, or cooking activities, knowing this information helps us plan responsibly and avoid any potential health risks. Please share anything we should know—even mild allergies—so we can take the proper precautions.
Food Allergies:*
Other food allergies:
Environmental Allergies:*
Other Environmental Allergies:
Medicine Allergies:*
Other Medicine Allergies:
Other Allergies:*
Any other allergies:
Health Insurance

We ask about health insurance coverage to ensure we’re prepared in case of an emergency. If a situation ever arises where your teen needs medical attention while in our care, having this information allows us to respond quickly and responsibly.
Insurance Carrier:*
Member/Policy Number*
Group Number*
Emergency Contact #1
Name*

First NameLast Name
Relationship to Club Member*
Phone Number (Mobile)*
Please enter a valid phone number.
Phone Number (Other)
Please enter a valid phone number.
Email
example@example.com
Is this contact authorized to pick up your teen from any BGCG-related event? *
Emergency Contact #2
Name

First NameLast Name
Relationship to Club Member
Phone Number (Mobile)
Please enter a valid phone number.
Phone Number (Other)
Please enter a valid phone number.
Email
example@example.com
Is this contact authorized to pick up your teen from any BGCG-related event?
Parent/Guardian Authorization
Parent/Guardian Name

First NameLast Name
Parent/Guardian Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Email
example@example.com
Phone Number (Mobile)
Please enter a valid phone number.
Phone Number (Other)
Please enter a valid phone number.
I, {parentguardianName} consent for my teen/child, {name30} to have an active Teen Membership with the Boys & Girls Club of Garfield, via the MyClubHub portal. I give the Boys & Girls Club of Garfield permission to update my child's profile with the provided information.

Signature*
{parentguardianName}
Today's Date*
Photo Release: I understand that the Boys & Girls Club of Garfield (BGCG) may wish to use photographs of my child for various promotional, educational, and documentation purposes. These photographs may include images of my child participating in BGCG activities, events, or programs.
Publishing Child's Work: I understand that from time to time, the BGCG may wish to publish examples of club member projects, club member-created media, and other work on an Internet accessible World Wide Web server (WWW). This may include my child's projects, artwork, and other forms of creative expression.
Parent/Signature

Clear
Should be Empty:

Parent/Guardian Permission for Teen Membership

Teen Member Information

Household & Demographic Information

Allergies

Health Insurance

Emergency Contact #1

Emergency Contact #2

Parent/Guardian Authorization