MEMBERSHIP APPLICATION FORM

20__ - 20__

CHILD’S NAME: ________________________________________________________

                                                        First                             MI                                   Last

ADDRESS: _____________________________________________________________

CITY: __________________________ ST: ____ ZIP: ___________________

HOME PHONE: (_____)_____________ CELL: (____)______________

CHILD’S DOB: ___________________ CHILD’S AGE: ____ MALE / FEMALE

CHILD’S RACE: __________________ HOUSEHOLD SIZE: _______________

CHILD RESIDES WITH: Both Parents Mother Father Grandparent Foster Other

MOTHER/GUARDIAN’S NAME: _________________________________________

MOTHER’S EMPLOYER: ________________________ WORK #: _______________

FATHER/GUARDIAN’S NAME: __________________________________________

FATHER’S EMPLOYER: _________________________ WORK #: _______________

ANNUAL HOUSEHOLD INCOME: 0-$15,000 $15,001-20,000 $20,001-25,000

$25,001-30,000 $30,001-40,000 $40,001-50,000 $50,001-UP

DOES CHILD RECEIVE FREE OR SUBSIDIZED LUNCH: YES / NO

Does the child have any physical, mental or emotional impairment of which the Boys & Girls Club of Hot Springs should be aware? If so, please list: ______________________

Is child currently taking any medication of which we should be aware? If so, please list:

_______________________________________________________________________

Does child have medical insurance? If so, please list: ____________________________

Name of child’s Physician & phone: _________________________________________

Name of person to notify if parent/guardian cannot be reached: _____________________

___________________ Phone #: ___________________________________________

Has child been a member of this organization previously? YES / NO

SCHOOL CHILD ATTENDS: ____________________ CURRENT GRADE: _______

--------------------------------------------------------------------------------------------Parent/Guardian’s permission to administer minor emergency care and/or seek emergency treatment for child? YES___ NO___

In consideration of my child’s membership and participation in the Boys & Girls Club of Hot Springs, I, as a parent/guardian of named minor, do hereby release the Boys & Girls Club of Hot Springs from all liability to me, my child, and my child’s personal representative, assigns and heirs from all claims and damages which my child or I may have against the Boys & Girls Club of Hot Springs and/or it’s sponsors resulting from participation in or connection to a Boys & Girls Club of Hot Springs related activity. I hereby authorize the Boys & Girls Club of Hot Springs, as my agent, to secure medical treatment as is deemed necessary and will, on behalf of said minor, assume and pay all expenses associated with such treatments in the event of an accident, illness or other incapacity. I will ensure that my child is fit and sufficiently trained to participate in the programs of the Boys & Girls Club of Hot Springs. I permit the Boys & Girls Club of Hot Springs to utilize photographs of my child taken of his/her involvement in the Boys & Girls Club of Hot Springs programs and hereby waive all rights of compensation for said use. I understand that the Boys & Girls Club of Hot Springs is not responsible for the time or manner in which my child arrives at or leaves the facility and I also understand that the Boys & Girls Club of Hot Springs is not responsible for lost or stolen items/personal belongings.

Parent/Guardian Signature: _____________________________ Date: ______________

Membership Number: ______________ Date: ___________________ New / Renewal