BOYS AND GIRLS CLUBS of CleveLand
2019 - ANNUAL YOUTH MEMBERSHIP APPLICATION – All applications expire on 31st of August each year.
 
MEMBERSHIP TYPE
MEMBER INFORMATION
Unit/Branch:*  
Child's Name:
(First)*

(Middle)

(Last)*

(Suffix)
Date of Birth:*
Age Group:*
Gender:*
Ethnicity:*
Primarily Plan to Attend:*
Phone:*
Current School Attending:*
Current Grade:*
Teacher:
Age 0
Based on the current school year, did your child advance a grade from the previous school year?*
Did your child have any part-time, summer or seasonal work during the past 12 months?*
Address:*
Country:*
State:*
City:*
Zip:*
At This Address Since: Allow Pickup: School District:*
Physical Features
Height: Weight:
Eye Color: Hair Color:
Has this child ever attended a Boys & Girls Club or program?:   If yes, please list:
HOUSEHOLD INFORMATION
PRIMARY GUARDIAN
Relationship:*
Is household member:*
Is parent/guardian interested in BGCC volunteer opportunities:
Name:
First Name*

Middle Name

Last Name*
Phone:* (Atleast one should be filled)
Home#: Cell#: Business#:
Best contact number for primary Parent/Guardian:
Home Phone Cell Phone Business Phone
Email Address:
Marital Status:*
Employer:
Check, if Address is same as Child's Address
Address:*
Country:*
State:*
City:*
Zip: *
SECONDARY GUARDIAN
Relationship:
Is household member:
Is parent/guardian interested in BGCC volunteer opportunities:
Name:
First Name

Middle Name

Last Name
Phone: (Atleast one should be filled)
Home#: Cell#: Business#:
Best contact number for secondary Parent/Guardian:
Home Phone Cell Phone Business Phone
Email Address:
Marital Status:
Employer:
Check, if Address is same as Child's Address
Address:
Country:
State:
City:
Zip:
HOUSEHOLD
Household Name:*
Housing Development:
Military Branch:*
Lives on Military Base? Is anyone that lives in your household a part of the military?*
Current Head of Household:
Single Parent:*

List number & age of siblings in household:
Sister(s)#:
ages: Brother(s)#:
ages:
How many people live in your house INCLUDING you?*
I Live With My:
Both Parents Mother Only Father Only Grandparent(s)  
Guardian Foster Care Group Home Other
Reason For Joining Club:
Fun Learning Sports Other
Check, if Address is same as Child's Address
Address:*
Country:*
State:*
City:*
Zip:*
EMERGENCY CONTACTS
Please list additional relative and/or friend to contact in case of an emergency and your parents cannot immediately be reached.
Name:
(First)*

(Middle)

(Last)
Gender:*
Relation: Phone:*
Name:
(First)*

(Middle)

(Last)
Gender:*
Relation: Phone:*
Confidential Information
The following is necessary for our records and the funding our organization receives. The answers you provide are confidential. Your cooperation in providing this information is both appreciated and necessary.
Combined household income is*
Does this member receive FREE lunches / Reduced price at school?*
 
HEALTH
Does your family have a physician or health insurance?*
List all medicine child is taking:
Hospital / Doctor you use: Permission for treatment by doctor/hospital:*
Prescription or Over the Counter Medications: *
If yes explain:
Medical Facility:
Insurance Policy Holder Number: Medical Treatment Permission:
Address:
Special Needs/Health Issues:*
If yes explain:
Special Medical Conditions:
Asthma Epilepsy Emotional/behavior disorder including AAD or ADHD
Diabetes Allergies
Cerebral palsy Other
The BGCC does not dispense or administer any medication to members. Medication can only be administered by the parent/guardian. Please refer to Parent/Member Handbook for entire policy on medications.
Acceptable Use Policy for Technology
I understand that my child will have access to club computer equipment and internet use and they will be held accountable for violation of the Clubs rules as stated in the Parent Handbook.
Authorized by parent/guardian for Acceptable Use Policy for Technology:*
Disclaimer
I, Parent of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Cleveland, and Boys and Girls Club of America, their representatives, successors, insurers, assigns or any other person or any entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands or cause of action dor any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the club.

 
Disclaimer:*
******************************************************************************* PARENT PERMISSION ******************************************************************************
My child is joining Boys & Girls Clubs of Cleveland with my permission. I understand that the club is an open-campus and not responsible for the time or manner in which he/she may arrive at or leave the club, and that BGCC is not responsible for injury, medical expense, or loss of personal property while this member is participating in club activities. If, in the opinion of BGCC staff, my child has a medical emergency, I give my permission for him/her to be examined/treated by licensed medical personnel at my expense. An ambulance may be called if deemed necessary for transportation. I give my express permission for my child to be transported to BGCC events by club or private transportation. By signing below, I also give my express permission for my child to be videotaped or photographed for publicity purposes. I agree to be financially responsible for any/all club equipment checked out by my child and not returned to the club in a timely manner. I agree to furnish transportation for my child to leave the club before the posted closing time for any given club day (or) to have a signed PARENTAL PERMISSION TO LEAVE OUTSIDE AT CLOSING form on file with club director. A $25.00 late fee will incur 15 minutes after closing and must be paid before the member’s next visit to the Club. Please remember that staff members also have obligations to attend to outside of the Club. Social Services will be called if you are an hour or more late. I understand that BGCC is a drug/alcohol free zone and that persons who violate this policy will be dealt with sternly I give permission for the BGCC to make and retain copies of my child's (or ward's) report cards and/or progress reports in order to better understand the academic needs of my child (or ward) and to better assist him/her in his/her educational pursuits. I understand that copies made of report cards and/or progress reports will remain confidential and will only be viewed by BGCC staff. I understand that certain units of the Boys & Girls Clubs of Cleveland may be designated for specific ages (age varies by Club location, please check with your Club). BGCC IS NOT A LICENSED DAYCARE. I have received a copy of the Parent Handbook/club rules and will cover them with my child. If my child is suspended for any reason, I will not expect the return of any dues/fees that I have paid to the club.
Member/Contacts Understood Signed Insurance Disclaimer & Permission Statement:*
Member has permission to be used in public relations materials:*
Member may participate in all Club activities in or adjacent to the club building:*
School Data Release Permission:*
General Travel Permission:*
Boys & Girls Club of Cleveland Club Rules:*
Data Collection
I give my permission to the Boys & Girls Clubs of Cleveland 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, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.
School Information I give my permission to the Boys & Girls Clubs of Cleveland and your child's school district to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Clubs and in life. This release is valid for one year and may be revoked at any time by contacting the Boys & Girls Club in writing.
Data Sharing I understand that the Boys & Girls Clubs of Cleveland may share information about the minor child listed on this application with Boys & Girls Clubs of America (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 Boys & Girls Clubs of Cleveland, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.
Authorized by parent/guardian for Data Collection/School Information/Data Sharing:*
 
Parent/Legal Guardian Name Printed:*
Date: 03/26/2019
Parent/Legal Guardian Signature:*
Member's Signature:*