Mobile Club Registration Form

Location Registering For?
Child's Information
NOTE - Children need to have completed Kindergarten before they are eligible to participate in the Boys & Girls Mobile Club.
Child's Information
Parents' Information

Parent/Guardian 1
Parent/Guardian 1

First NameLast Name
Relationship to Child
E-mail
example@example.com
Cell Phone
Format: (000) 000-0000.
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 2
Parent/Guardian 2

First NameLast Name
Relationship to Child
E-mail
example@example.com
Cell Phone
Format: (000) 000-0000.
Home Address Same as Parent/Guardian 1?
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Emergency Contacts/Authorized Pickup

Parents cannot be listed as emergency contacts. List the name of at least one person who can be contacted in the event of an emergency or illness if you cannot be reached. Any person listed should be able to assist in contacting you. At least one person listed must be within one hour of the center/home, able to take responsibility for the child in case the parent/guardian cannot be contacted and should be at least 18 years of age. The first emergency contact must live no more than 1 hour away and be over the age of 18.
Emergency Contact #1
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Format: (000) 000-0000.
Relationship to Child
This person is authorized to pick up my child.
Emergency Contact #2
Full Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Phone Number
Format: (000) 000-0000.
Relationship to Child
This person is authorized to pick up my child.

Statement of Understanding
Acknowledgement of Policies and Procedures I have reviewed and received a copy of the center's policies and procedures/handbook.
Sign Document
Date Signed

MonthDayYear
Should be Empty: