Boys & Girls Clubs of Oklahoma County

MEMBERSHIP APPLICATION

Boys & Girls Clubs of Oklahoma County

Date: ______

First Name: ______Middle: ______Last: ______

Nickname: ______

Gender: ___M ___F Ethnicity: ______Birthdate: ______

Address: ______

City: ______State: ______Zip: ______

Phone: ______Email: ______

School Information:

Current Teacher: ______Current GPA: ______

School: ______Grade: _____ Free or Reduced Lunch: ___Yes___No

Medical Information:

Doctor Name: ______Doctor Phone: ______

Date of Last Medical Exam: ______

Permission for Treatment by Doctor/Hospital: ____Yes ____No Medicaid: ____Yes ____No

Does your family have health and/or accident insurance: ____Yes ____No

Insurance Carrier: ______Insurance Phone: ______

Policy #: ______Group#: ______

Date Health Info Received: ______

Serious Health Problems: ___Yes ___No If Yes, explain: ______

Medications: ___Yes ___No If Yes, explain: ______

Date Medical Info Received: ______

Shots: / Hepatitis / MMR / HIB / Polio / DTP Shot / Chicken Pox
1st Shot / ______/ ______/ ______/ ______/ ______/ ______
2nd Shot / ______/ ______/ ______/ ______/ ______/ ______
3rd Shot / ______/ ______/ ______/ ______
4th Shot / ______/ ______
5th Shot / ______

General:

Birth Certificate on File: ____Yes ____No Birth City: ______Birth State/Country: ______

Member/Contacts Understood Signed Insurance Disclaimer and Permission Statement: ____Yes ____No

Member has permission to be used in public relations materials: ____Yes ____No

Member may participate in all Club activities in or adjacent to the club building: ____Yes ____No

Club Member Since: ______Religion: ______

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Household: NOTE: This information is collected for Grant writing purposes ONLY

Member lives with: ____Mom ____Step Mom ____Dad ____Step Dad ____Grandparent

____Foster parent(s) ____Other: ______

Housing Development: ______

Annual
Income
Level: / $0 - $5000 _____ / $30,001 - $35,000 _____ / $60,001 - $65,000 _____
$5001 - $10,000 _____ / $35,001 - $40,000 _____ / $65,001 - $70,000 _____
$10,001 - $15,000 _____ / $40,001 - $45,000 _____ / $70,001 - $75,000 _____
$15,001 - $20,000 _____ / $45,001 - $50,000 _____ / $75,001 - $80,000 _____
$20,001 - $25,000 _____ / $50,001 - $55,000 _____ / $80,001 - $85,000 _____
$25,001 - $30,000 _____ / $55,001 - $60,000 _____ / $85,001 - $90,000+ _____

Number in Household: ______

Is there a Member of the Household 65 years old or Older: ____Yes ____No

Is there a Member of the Household Handicapped: ____Yes ____No

Current Head of Household: ____Female ____Male ____Both

Current Single Parent: ____Yes ____No

Physical:

Eye Color: ______Hair Color: ______Skin Color/Features: ______

Height: ______Weight: ______

Do you Belong to other Groups:

___ Boys Scouts or Girl Scouts ___ School Club ___ YMCA or YWCA ___ Church Group

___ Other: ______

Reason(s) for joining: ____ Fun ____ Learning ____ Sports ____ Other: ______

Disclaimer:

I, ______, do hereby give my son/daughter ______permission to attend and participate in activities sponsored by the Boys & Girls Club. I hereby release the Boys & Girls Club, its employees, associates and contributors from liability from any injury, loss of theft incurred by my son/daughter while participating. Furthermore, I hereby authorize medical examination and emergency treatment for my son/daughter by a qualified licensed physician in the event of an accident. I further understand that the Boys & Girls Club has an “open door” policy, which means that my son/daughter may come and go at will. I also give permission for my child’s pictures to be used in any Boys & Girls Club publication. My signature indicates that I completely understand the above statement.

Parent’s Signature: ______Member’s Signature: ______

FOR OFFICE USE ONLY Membership #: ______

Entry Date: ______Expiration Date: ______Status: ______

Type: ______New/Renewal Member: ______Processed by: ______

OPEN DOOR POLICY

Boys & Girls Club of Oklahoma County’s open door policy allows members to enter the club at any time during regular club hours. We expect parents and members to agree upon clear attendance expectations (length of stay, transportation, frequency of attendance). Members who choose to leave club premises must be accompanied by a parent to re-enter the club on the same day.

I have read and understand the above statement. ______

Parent/Guardian Signature

PICK UP AND CONTACT INFORMATION

Parent/Guardian ______Employer______Address ______

Work Phone______Cell Phone ______Alt. Phone ______

Parent/Guardian ______Employer______Address ______

Work Phone______Cell Phone ______Alt. Phone ______

The following people are allowed to pick up my child on a regular or emergency basis:

Name ______Relationship ______Phone______

CONSENT FOR DISCLOSURE OF MINOR STUDENT’S EDUCATIONAL RECORDS

Date:______

I give my permission to the Boys & Girls Club of Oklahoma County to request and obtain educational records belonging to the minor child listed on this form for research purposes. I understand that this information may be shared with Boys & Girls Clubs of America in order to analyze effectiveness of club programs. Information that will be disclosed to BGCA may include information provided on the membership application form, information provided by the minor child's school district, and other information collected by Boys & Girls club of Oklahoma County, including data collected via surveys or questionnaires. Furthermore, I also give my consent to the Boys & Girls Club of Oklahoma County to request information from the minor child's school district. All information provided to the BGCA will be kept confidential.

In accordance with an after school reading, tutoring and intervention partnership with Payne Education Center of Oklahoma City, I give permission for Payne qualified professionals to administer appropriate literacy/reading assessments of my child

Child’s Name (Printed)

Parent/Guardian’s Name (Printed)

Parent/Guardian’s Signature Date