Membership Application

Membership Application
Child's Name*

First NameMiddle NameLast Name
Nick Name

First Name
Gender*

MaleFemaleOther
Date of Birth*

MonthDayYear
Date
Ethnicity (select all that apply)*

American Indian or Alaska NativeAsianBlack or African AmericanNative Hawaiian or Other Pacific IslanderWhite
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Name

First NameLast Name
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
School Information
Current Teacher, School, and Grade*
Medical Information
Doctor's Name
Doctor's Phone Number
Please enter a valid phone number.
Date of Last Medical Exam

MonthDayYear
Date
Permission to treat by Doctor/Hospital?*

YesNo
Does your family have health insurance?*

YesNo
Insurance Carrier, policy and group number*
Medi-Cal Number (this will determine if your child is eligible for additional services):
Allergies? If yes, please explain*
Serious health problems? If yes, please explain*
Medications? If yes, please explain*
Permissions
Member/Contacts understood signed insurance disclaimer and permission statement?*

YesNo
Does member have permission to be used in Public Relations Materials?*

YesNo
Member has authorization to receive transportation to and from field trips.*

YesNo
Member has authorization to walk home from the club.*

YesNo
I authorize the school to release the members report card to Boys & Girls Club of Manteca and Lathrop*

YesNo
Members of BGCML are welcome to participate in an anonymous online survey to see how their experiences in the Club rank in comparison to other clubs in the country. The results may be used to gather data for reporting to funding agencies like United Way. I authorize the Club to allow my child to access the Internet under the supervision of the staff:*

YesNo
In the event reasonable attempts to contact me at the provide phone numbers are unsuccessful, I hereby give my consent for the administration of any emergency medical or dental treatment deemed necessary by licensed or certified medical personnel for the health and well being of the child named in this application. I further agree not to hold the Club liable for any medical bills resulting from injuries that my child may incur at The Club:*

YesNo
Club activities may include, but are not limited to: basketball, volleyball, dodge ball, various games of running and tagging, use of computers, electronic games, board games, homework help and use of books, general and special interest magazines, activities with plants, table games such as billiards, ping pong, foosball, card games, magic tricks, fashion show, talent shows which feature proficiency in visual art, music, and dance, and social events such as dances and parties. Member may participate in all Club activities in or adjacent to the club building:*

YesNo
I understand for each child here after closing there will be a late fee of $1.00 per minute. The late fee is to be paid upon pick-up. The member is not allowed back until the payment has been received. Authorities will be contacted 30 minutes after The Club closes if there has been no contact with parents/guardians. Members are not permitted to wait outside for rides, once checked out, they may not loiter on Club property:*

YesNo
Household

NOTE: This information is collected for Grant and Funding purposes ONLY. Without this information, the Club may not be eligible for certain grants. We appreciate your cooperation. All information is confidential.
Member lives with*

MotherStepmotherFatherStepfatherGrandparent(s)Foster Parent(s)Sibling or Aunt/Uncle
Combined Gross Income*
Number in Household*
Is there a member of the household 65 years old or older:*

YesNo
Is there a member of the household handicapped:*

YesNo
Current head of household:*

FemaleMaleBoth
Current Single Parent*

YesNo
Physical
Eye Color*
Hair Color*
Height & Weight*
Does the member belong to other groups?*
Reason for joining*

FunLearningSportsSocializationOther
Open Door Policy

Open Door Policy: Membership in the Boys & Girls Clubs of Manteca/Lathrop (BGCML or “the Club”) is open to all children between the ages of 6 and 18, without regard to sex, race, or religion. All members are entitled to come to the Club during regular operating hours and to participate in all of the Club’s programs, subject to restrictions that may limit age groups or hours for specific programs. All members are required to complete a membership application and to show a membership I.D. when entering the Club. BGCML is not a custodial care agency: does not have the right or responsibility to keep a child at the Club; and does not assume responsibility for members when they leave the Club. The Club does, however, ask that all members sign out at the registration desk each time they leave the Club. If parents or guardians give their children instructions regarding attendance at the Club, we ask that a written copy of the instructions be given to the membership secretary.Disclaimer: The Boys & Girls Clubs of Manteca/Lathrop is not responsible or liable in any way in the event of harm or injury occurring to the member. It is agreed that the parent or guardian will not hold Boys & Girls Clubs of Manteca/Lathrop responsible for the welfare or whereabouts of the member. If the Parent or Guardian does file a complaint against the Club the Parent or Guardian agrees to pay for Boys & Girls Clubs of Manteca/Lathrop legal fees. I am the parent or legal guardian of the child named in this application. I request that my child be admitted to membership in the Boys & Girls Clubs of Manteca/Lathrop, and I give my permission for the activities described above. I certify under penalty of perjury that income and household statements made on this form are true
Parent Name*

First NameLast Name
Signature*

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Date*

MonthDayYear
Date
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