Member Registration Form

Information for First Member

If you are registering your child at BJHS and they may attend Teen CLUB please select both options.

Club Site*
Member First Name*
Member Last Name*
Date of Birth (mm/dd/yyyy)*
Race*
Food allergies: check all that apply*
Other concerns:*

Information for Second Member (optional)

If you are registering your child at BJHS and they may attend Teen CLUB please select both options.

Club Site
Member First Name
Member Last Name
Date of Birth (mm/dd/yyyy)
Race
Food allergies: check all that apply
Other concerns:

Information for Third Member (optional)

If you are registering your child at BJHS and they may attend Teen CLUB please select both options.

Club Site
Member First Name
Member Last Name
Date of Birth (mm/dd/yyyy)
Race
Food allergies: check all that apply
Other concerns:

Information for Fourth Member (optional)

If you are registering your child at BJHS and they may attend Teen CLUB please select both options.

Club Site
Member First Name
Member Last Name
Date of Birth (mm/dd/yyyy)
Race
Food allergies: check all that apply
Other concerns:

Information for Fifth Member (optional)

If you are registering your child at BJHS and they may attend Teen CLUB please select both options.

Club Site
Member First Name
Member Last Name
Date of Birth (mm/dd/yyyy)
Race
Food allergies: check all that apply
Other concerns:

Parent/Guardian Information- Primary Contact

Country*
Email*
Confirm Email*
Phone*
Mobile Phone Number*
Secondary Phone Number

Parent/Guardian Information- Secondary Contact

First Name
Last Name
Mobile Phone Number
Secondary Phone Number
Email

Household Information

Who does your child live with? Check all that apply.*

Emergency Contacts and Persons Authorized for Member Pickup (Please include all approved persons not currently listed on the application)

Emergency Contact First Name*
Emergency Contact Last Name*
Emergency Contact Phone*

Authorization and Release

By checking the box below, I agree with the following statements:

 

1. I will review and understand the Family Handbook and will sign a copy of the Family Release prior to my child starting at the Club.

 

2. I will sign up for Family Orientation. 

 

3. I verify that the above income information is correct and understand that I may be asked to apply for CCAP for my child(ren). I understand if I am not accepted into this program there are other scholarship opportunities for my child to attend the Club. I understand if I am eligible for either program I am still responsible for the $25 Annual Membership Dues prior to my child attending the Club.

 

4. I will sign up for Remind and I understand that it will be the primary form of communication between my family and the Club.

 

5. I am aware of the program’s calendar and it is my responsibility to stay up to date with the calendar to be aware of what is going on as well as Club closures.

 

6. I understand that my child will not be enrolled in the program until all information requested is received by the Boys & Girls Club.

Authorization*

Links to all information requested of you will be sent in an email following your submission. Once all the requested information is available to the Club, your child will be registered. At that time we will contact you to ensure we have the space to admit your child into the Club. At that time the $25 application fee will be due and any additional scholarship paperwork will be given to you for completion.

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