Boys & Girls Clubs of Greater Flint

Membership Application

 

Membership Application

 
 
Club Member Information
Birthdate *
Birthdate
Race/Ethnicity *
Address *
Address
Cell Phone *
Cell Phone
Home Phone *
Home Phone
Pick-Up Information
Emergency Contact *
Emergency Contact
(someone who does not live with member)
Emergency Contact Phone Number *
Emergency Contact Phone Number
Authorized to Pick-Up Member #1 *
Authorized to Pick-Up Member #1
Authorized to Pick-Up Member #1 Phone Number *
Authorized to Pick-Up Member #1 Phone Number
Authorized to Pick-Up Member #2 *
Authorized to Pick-Up Member #2
Authorized to Pick-Up Member #2 Phone Number *
Authorized to Pick-Up Member #2 Phone Number
Family History
Mother *
Mother
Mother's Phone Number *
Mother's Phone Number
Father
Father
Father's Phone Number
Father's Phone Number
Guardian
Guardian
(if different from mother or father)
Guardian's Phone Number
Guardian's Phone Number
Medical Information
Doctor *
Doctor
Doctor's Phone Number *
Doctor's Phone Number
Confidential Information
The following information 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.
All Services Household is Currently Recieving *
Club Rules
The Boys & Girls Clubs of Greater Flint have an open door policy. This means that it is the parent's responsibility to make sure that their child remains at the Club and does not leave the premises what you expect him/here to be here. We urge you to please emphasize this with your child. Members and guests should always follow the Four Club Rules: 1. Respect Others, 2. Respect Staff, 3. Respect Yourself, 4. Respect the Club. Members and guests are encouraged to use the Peace Options when resolving conflicts: 1. Compromise, 2. Apologize, 3. Get Help, 4. Walk Away. All food and drinks are to be consumed in the cafeteria only. Gum is not permitted in the Club. Boys & Girls Club members, when absent from school due to illness or termination fo any kind, may not attend Club activities on those days as it represents a threat to the health/safety of others. Jackets, purses, backpacks or any other bag or exterior clothing must be kept in the coatroom and may not be carried/worn around the building during Club hours. Appropriate footwear must be worn at all time (closed toe.) Tennis shoes are required to participate in the gym. All prescription and non-prescription medications must be dispensed by Club staff. Medication must be accompanied by a signed and current medicine Dispensing Agreement. Cell phone and electronics are not allowed at the Club, members will be asked to turn these items in to staff until dismissal. Members who refuse will be asked to leave the facility.
Read & Sign
I give permission to the Boys & Girls Clubs of Greater Flint 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. The Club will not be responsible for any accident to the child while on the premises or while engaged in any off-site activities with the Club. I give my permission to the Boys & Girls Clubs of Greater Flint 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. As a member of the Boys & Girls Clubs of Greater Flint, your child will have access to the internet. While precautions are taken, it is possible he/she may access inappropriate sites. The Boys & Girls Clubs of Greater Flint will have rules and consequences at the Club for such behavior. I give my permission to the Boys & Girls Clubs of Greater Flint and my school district to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organzations do a better job of helping the student be successful in school, at the Club and in life. I understand that the Boys & Girls Clubs of Greater Flint is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. As a drop-in facility, we are not responsible for Club members' whereabouts. I give permission for my child's picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Clubs of Greater Flint in any appropriate manner they choose. I give my permission to the Boys & Girls Clubs of Greater Flint to share information about the minor child listen on the application with the Boys & Girls Clubs of America, Club staff, funders and other community stakeholders for research purposes and/or to evaluate the program's effectiveness. Information disclosed to the Boys & Girls Clubs of America may include the information provided on this membership application form, information provided by the minor child's school district and other information collected by the Boys & Girls Clubs of Greater Flint, including data collected via surveys or questionnaires. All information provided to the Boys & Girls Clubs of America will be kept confidential. I request that my child be admitted into membership at the Boys & Girls Clubs of Greater Flint. I have read and understand the Boys & Girls Clubs of Greater Flint rules, regulations and policies and have communicated them effectively to my child.
Club Member *
Club Member
Club Member Signature *
Parent or Guardian *
Parent or Guardian
Parent or Guardian Signature *
Today's Date *
Today's Date