Non-Refundable Registration FeesDunnellon Branch
$20 Membership + $10 Reg
NOT RESPONSIBLE FOR LOST OR STOLEN
ELECTRONICS
Afterschool Program Fee: $40 per
child per month
Boys & Girls Clubs of Marion County
2015 - 2016MEMBERSHIP APPLICATION
First Name: ______Middle: ______Last: ______
Address: ______Lived at this Address Since: ______
City: ______State: ____ Zip: ______Telephone: ______Birth Date: ______Current Age: ____ Emergency Telephone: ______Ethnicity: ______Gender: ____Male ____Female
School Information:
Current School: ______Current Grade: ______
Food Program: Free Lunch______Reduced Lunch______
How long a Member in Years: ______Club Member Since: ______
Do you live with you’re: ___Mom ___Step Mom ___Dad ___Step Dad ___Grandparent ___Other: ______
Current Single Parent: _____YES _____NO Current Number in Household: ______
Number of Brothers: _____ Number of Sisters: _____
Annual Household Income:$ 0 to 15,000 ______$ 25,001 to 30,000 ______
$ 15,001 to 20,000_____$ 30,001 and above _____
$20,001 to 25,000 _____
Afterschool Program Fee: $40 per child per month
PARENT/GUARDIAN PARENT/GUARDIAN
Name:______Name:______
Employer:______Employer:______
Phone: ______Type______Phone______Type______
Phone:______Type______Phone______Type______
EMAIL ADDRESS: ______
Authorized to Pick upAuthorized to Pick up
Name:______Name:______
Address H______Address H______
Relationship______Relationship______
Phone:______Type______Phone______Type______
Phone:______Type______Phone______Type______
(continued)
The Boys & Girls Club of Marion County has received a grant through the State of Florida to run SMART Moves for each member of our Club. This program will be run quarterly and sessions will last between 30-45 minutes. The State of Florida has given us approval to use our National SMART Moves Program to implement this grant. The program content is based on age and will teach our kids to make SMART decisions and avoid the negative effects of peer pressure. What a great opportunity for our children. Once they have completed two sessions of the SMART Moves program they are done for the year. We hope to repeat this every year at our Club.
PARENT AUTHORIZATIONS:
I give the Boys & Girls Clubs of Marion County permission to view my child’s school grades, attendance and juvenile justice records. I authorize my child to take part in surveys that could help the Boys & Girls Club determine the effectiveness of the services provided. I give permission for my child to take part in supervised activities including internet use. I authorize medical examination and emergency treatment for my child by a qualified licensed physician in the event of an accident. I give permission for my child’s picture to be used in Boys & Girls Clubs media activities. My signature indicates that I completely understand the above statements.
Due to the “Come & Go “policy of the Boys & Girls Clubs, I understand that the club is not responsible for the time and manner in which my child may arrive and leave the club.
Parents Signature______Date______
FOR OFFICE USE ONLYMembership#: ______Receipt #______
Amt Paid: ______Expiration Date: ______Scholarship Approval: ______
New or Renewal Member: ______Processed by: ______Date______
Additional Comments:
______