Child Membership Registration Form

Child Membership Registration Form

Please provide the child's details and guardian contact information to complete the registration.
Registration is for children ages 6 to 18 years old.
Child's Full Name

First NameLast Name
Child's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Child's Gender

Other
Child Race selection
Enrolled tribe
Which school does the child attend?
Grade
Is school lunch free?
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Full Name

First NameLast Name
Household Information

Please share the following household details.
Household Income
How many people are in the household?
What assistance do you currently receive?

Other
Parent/Guardian Email
example@example.com
Parent/Guardian Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Contacts
Authorized Contact Name

First NameLast Name
Pickup Permission
Authorized Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Authorized Contact Name

First NameLast Name
Pickup Permission
Authorized Contact Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Does your child have any allergies or medical conditions?
Please list allergies and medical conditions
Please list any special needs, medications, or additional information we should know.
Transportation: Parents and Club members may be responsible for their own transportation to and from the Club, unless otherwise specified. Kids have permission to ride vans for field trips and other club activities.
Transportation Signature
Data Collection: I give my permission to the BGCEST to collect information via online or written surveys, questionnaires, interviews and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, BGCA, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members. This release may be revolved at any time by contacting the BGCEST in writing.
Data Collection Signature
Medical: I give permission to the BGCEST to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment.
Medical Signature
Insurance Carrier
Policy Number
Technology: As a member of the Boys & Girls Club, our child may have access to the internet. While the Boys & Girls Club has rules prohibiting such conduct and precautions are taken by the Club to prevent such access, it is possible your child may access inappropriate sites. The Boys & Girls Club will not be responsible for such unauthorized access.
Technology Signature
Data Sharing: I give my permission to the BGCEST to share information about the minor child listed on this application with 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, information provided by the minor child’s school or school district, and other information collected by BGCEST, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential. This release may be revoked at any time by contacting the BGCEST in writing.
Data Sharing Signature
Miscellaneous: I understand that the Boys & Girls Club is not responsible for lost or stolen items. Each Club has the right to make membership decisions based on the resources and capacity of their facility and staff. BGCEST reserves the right to decline the application, rescind the enrollment of, or suspend any youth that cannot successfully associate with other club members.
Miscellaneous Signature
Press: I give my permission for my child’s picture, video image, or any other graphic depiction or likeness, to be used by BGCEST, Boys & Girls Clubs of America and its affiliates or donors and acknowledge neither my child nor I will receive payment for same.
Press Signature
By submitting this application, I hereby give my permission to Boys & Girls Clubs of the Eastern Shoshone Tribe to collect and share data for the minor child listed on this application with Boys & Girls Clubs of America (BGCA). Data will only be reported in the aggregate and will exclude all references to any individual responses. All information provided to BGCA will be kept confidential.
By submitting - Signature
By submitting - Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
After School Programming Registration
Should be Empty:

Child Membership Registration Form

Household Information

Authorized Contacts