2025 Academic Year Registration Form

2025 Academic Year Registration Form

Registration is available only to ages 6 - 18.
Club Branch or School Based Club*

Bernard Malkove Branch Road South Mobile, AL 36608Foley Branch 1391 S. Cedar Street Foley, AL 36535Kiwanis Branch 712 Rice Street Mobile, AL 36607Semmes Branch 3810 Wulff Road East Semmes, AL 36575Sonny Callahan Branch 6585 Carol Plantation Road Theodore, AL 36582Camp Chandler-Tonsmeire 2701 South Shelton Beach Road Mobile, AL 36618School Based: Williamson High School and Middle Grades Preparatory Academy 1567 East Dublin Street Mobile, AL 36605School Based: Whitley Elementary School 528 Capt. Leon C. Roberts Street Prichard, AL 36610
MEMBER INFORMATION

1st Child in Family
Name

First NameMiddle NameLast NameSuffix
Date of Birth *

MonthDayYear
Date
Gender*

MaleFemale
Ethnicity*

Latino/ HispanicNon-Latino/Hispanic
Race*

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteMulti- Racial
Does your child require an Authorized pick up (as listed on the attached form) or will they walk to and from the Club?*

Authorized Pick-upWalker
*Boys & Girls Clubs of South Alabama will not be held responsible for your child's well-being once he/she leaves the building.
School*
Grade*
Does your child have any special needs allergies or health issues? If so, please explain:*
Does your child take any medications ? If so, please list medications and briefly describe what they are for:*
If this child is a new member, How did you hear about the Boys & Girls Clubs?*
T-Shirt Size*
MEMBERSHIP INFORMATION

2nd Child in Family
Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Ethnicity

Latino/ HispanicNon-Latino/Hispanic
Race

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteMulti- Racial
Does your child require an Authorized pick up (as listed on the attached form) or will they walk to and from the Club?

Authorized Pick-upWalker
*Boys & Girls Clubs of South Alabama will not be held responsible for your child's well-being once he/she leaves the building.
School
Grade
Does your child have any special needs allergies or health issues? If so, please explain:
Does your child take any medications ? If so, please list medications and briefly describe what they are for:
If this child is a new member, How did you hear about the Boys & Girls Clubs?
T-Shirt Size
Membership Information

3rd Child in Family
Name

First NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Ethnicity

Latino/ HispanicNon-Latino/Hispanic
Race

American Indian or Alaskan NativeAsianBlack or African AmericanNative Hawaiian or Pacific IslanderWhiteMulti- Racial
Does your child require an Authorized pick up (as listed on the attached form) or will they walk to and from the Club?

Authorized Pick-upWalker
*Boys & Girls Clubs of South Alabama will not be held responsible for your child's well-being once he/she leaves the building.
School
Grade
Does your child have any special needs allergies or health issues? If so, please explain:
Does your child take any medications ? If so, please list medications and briefly describe what they are for:
If this child is a new member, How did you hear about the Boys & Girls Clubs?
T-Shirt Size
Parent/ Guardian Contact Information
Parent/ Legal Guardian 1 Name*

First NameLast Name
Relationship to Child(ren) Registering for Membership*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone*
Home Phone*
Place of Employment *
Work Phone
Work Address
Signature of Parent Legal Guardian 1*

Clear
Date*

MonthDayYear
Date
Parent/ Legal Guardian 2 Name

First NameLast Name
Relationship to Child(ren) Registering for Membership*
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Cell Phone
Home Phone
Place of Employment
Work Phone
Work Address
Signature of Parent Legal Guardian 2

Clear
Date

MonthDayYear
Date
Family Confidential Household Information

This information is vital to data and funding for Boys & Girls Clubs of South Alabama. Please answer honestly.
Child currently lives with: (Check all that apply and how many:-i.e. __3__ sisters)
MotherFatherStepmotherStepfatherGrandmotherGrandfatherSister
BrotherAuntUncleNeiceNephewFoster ParentsOther
This child(s) meets the definition of homelessness according to the McKinney- Vento Homeless Assistance Act.*

YesNo
Are child/children visiting for the summer?*

YesNo
If yes, from where ?
Number of people living in household*
Current Head of Household*

MaleFemale
Total Household Income (list monthly or annually): (Required)
Monthly
Annually
Do you currently live in a Public Housing Development?*

YesNo
If yes, which one?
Are the parents' guardians members of the military past or present If yes which military branch*

YesNo
If yes, which one?
Medical Contact Information
Name of Members Medical Provider*
Providers Phone Number*
Address of Doctors Office *
Instructions regarding how parent/ guardian may be reached in an emergency: *
Parental Release
Parental Release

I, the parent/guardian of the minor child (children) on this application, request admittance to membership in the Boys & Girls Clubs of South Alabama, Inc. (hereinafter "BGCSA) and I will be responsible for any damage or destruction that his/her/their actions may incur.

Medical Treatment

I agree to not hold the BGCSA or its representatives responsible for injuries or accidents in connection with the Club's activities, and authorize the Club to administer first aid in case of accident. I also give the Club permission to authorize and obtain permission for emergency treatment. I fully understand that the BGCSA carries insurance which covers sponsored and supervised Club activities INCLUDING tackle football, and while traveling as a member of a group under supervision of the participating organization, directly, to or from such scheduled and supervised activity.

Technology

As a member(s) of the BGCSA, your child (children) will have access to the Internet. While precautions are being taken, it is possible he/she/they may access inappropriate sites. The BGCSA has rules and consequences for such behavior; however we will not be responsible for the consequences of such access.

Demographic Information

I give my permission to the BGCSA to share demographic and programmatic information about the minor child (children) listed on this application with Boys & Girls Clubs of America (hereinafter "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 (excluding name & address), information provided by the minor child's (children's) school or school district, and other information collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

Miscellaneous

I understand the BGCSA is not responsible for lost or stolen items. I further understand the Club is not a day- care center and does not assume responsibility for my child (children) if he/she/they leave the Club at any time during hours of operation. Also, due to the fact that we are not a licensed day-care, we cannot provide documentation concerning the cost for membership and program fees. I have received the Parent Handbook, agree with its content, discussed the rules with my child (children) and accept responsibility for all fees associated with my child's (children's) membership in BGCSA.

Photo & Publication I HEREBY CONSENT to the use, publication or display by or on behalf of the BGCSA of any photographs and any reproduction thereof or any video or voice recordings in which my minor child (children) may be portrayed or identified. I understand that the BGCSA may use, publish and display such photos, reproductions, videos, or voice recordings thereof, in whole or in part, for any promotional purpose. I waive all claims for any compensation for such use.4

Sources of publication or broadcast may include newspapers, magazines, TV or radio stations, promotional publications, web sites, Facebook, Twitter, exhibits, internal or external newsletters, e-newsletters, or any other informational material prepared by the BGCSA. The BGCSA may use pictures, films, or recordings in any BGCSA information materials or in response to requests from news media or outside agencies, which depict BGCSA programs and membership activities at the BGCSA. I waive all claims for any compensation for such use.

Thereby, I give permission to BGCSA to use my minor child's (children's) first and last name, grade level in school, school name and location, and any stories associated with their participation in the BGCSA program to the media.
Please initial you acceptance in the box.*
Permission to Participate
Activities away from the Facility*

YesNo
Transportation provided to and from club, including pickup from school & fieldtrips*

YesNo
Swimming/wading activities provided by the facility*

YesNo
I understand that the Department of Human Resources does not inspect activities away from the childcare facility (home or center). The licensee of the childcare facility assumes full responsibility for such activities.
Signature of parent guardian*

Clear
Is any member of your family a Boys & Girls Club Alumni?*

YesNo
If yes, please list: Name, Club Attended & Email
PLEASE NOTE THAT ALL MEMBERSHIPS EXPIRE AT THE END OF SCHOOL YEAR 2026.
BOYS & GIRLS CLUBS OF SOUTH ALABAMA, INC.
Emergency Contact / Pick Up Authorization
Fill out this form completely. Your child’s safety depends on it.
x Anyone, including parents, who are authorized to pick a member up, must be included on this list.
x If any individual’s information is incomplete, that person will NOT be allowed to pick up a member. NO EXCEPTIONS.
Parent Guardian

First NameLast Name
Contact's First Name: EMERGENCY CONTACT Please check ALL that apply: NON-PARENT
Contacts First Name
Last
Relationship to Member
Phone - Home
Phone - Work
Email
example@example.com
Contact's Name: EMERGENCY CONTACTPlease check ALL that apply: NON-PARENT
Contacts Name
Last
Relationship to Member
Phone - Work
Email
example@example.com
I give my permission as parent/legal guardian of the child stated below for the individuals listed on this form to pick up my child from the Boys & Girls Club of South Alabama. I further understand the Club is not a day care center and does not assume responsibility for my child if he/she leaves the Club at any time during hours of operation. I also understand that any change requests to this form must be completed by an authorized staff member.

Child's (Children's) First Name:
1
2
3
ParentLegal Guardian First Name
Last
Signature of ParentLegal Guardian

Clear
Staff Initial
BGC/DHR Project Affirmation and Certification for TANF Ellgibility (This form applies only to services funded by DHR)
Name of ParentCaretaker Relative
SSN
Spouses Name if in home
SSN
Address

Address

Street Address Line 2

CityState

Zip CodeCounty
Phone
A. Are you the parent or caretaker relative of a child living with you who is age 5 to 18? Yes B. Are you and the child(ren) residents of Alabama? Yes If the answer to A or B above Is no, you are not TANF eligible. If the answer to A and B Is yes, go to the next section.

List the name, relationship to you and date of birth for participating children. Date of Birth Name of Child Relationship

For the child(ren) listed above, indicate whether you receive benefits from any of the following programs: Family Assistance (FA) YesNoFood Assistance (Food Stamps) Yes No Medicaid Child Care If the answer Is yes to participating in any of the above programs, skip to the Affirmation and Agreement Section. If the answer to all of the programs above is "no" and you are a parent, use the section below to report your family's size. To determine correct family size, include yourself, your spouse in the home, your children and other related children in your care under age 18 living in your home. Circle the correct family size on the chart below. Size of Family UnitSize of Family Unit Size of Family UnitSize of Family Unit 7 14 10 5 11 6 12 If you are a parent, enter your name and that of your spouse (if in the home), amount of monthly gross income and source. Examples of income: Wages, Social Security, SSI, unemployment compensation, etc. Monthly Gross Income Source or Type of Income 1. 2. Total Family Monthly Gross Income Listed Above

Affirmation and Agreement: I certify under penalty of perjury the information given above, including family size and monthly gross income, is correct and true to the best of my knowledge. I further certify that the child(ren) listed above is a U.S. citizen or alien in satisfactory immigration status. I understand that our social security number(s) may be used in computer matching to verify identity and income. I give the BGC/DHR permission to verify information I provided on this form.
Date

MonthDayYear
Date
ApplicantParentCaretake Relative Signature

Clear
Return completed form to the Boys and Girls Club serving your area. BGC Use Only: TANF Eligible? YesNo
Eligibility Determined by
Boys Girls Club
DHR-BGC-2074 (10-1-13) Distribution: Original retained by BGC for three years plus current.
Date

YearMonthDay
Date
Should be Empty:

2025 Academic Year Registration Form

MEMBER INFORMATION

MEMBERSHIP INFORMATION

Membership Information

Parent/ Guardian Contact Information

Family Confidential Household Information

Medical Contact Information

Parental Release

Permission to Participate

Contact's First Name: EMERGENCY CONTACT Please check ALL that apply: NON-PARENT