110 S Ree Street – PIERRE SD 57501 – 605-224-8699
Membership Application 2012 - 2013
Assigned Member ID #: Membership Fee $5.00 Fee Paid ______
Cash ______
Date Application Rcvd New Renewal Check #______
Date Data Entered By (staff initials)
MEMBER INFORMATION
Last Name:______First: ______Middle: ______
Nickname: ______Age: ______Birthdate: ______Gender:______
Race/Nationality (please circle one): African American African American/Caucasian Asian/Pacific Islander Caucasian Hispanic Native American Native American/Caucasian Other______
Home Address: ______
Parent/Guardian EMAIL Address:______
Name of School: ______Grade ______EK and K thru 12th Grade are eligible.
CONTACT INFORMATION
Mother’s Name: Mother’s Home #:
Mother’s Cell #:
Mother’s Employer: Mother’s Work #:
Father’s Name: Father’s Home #:
Father’s Cell #:
Father’s Employer: Father’s Work #:
------
OR, if applicable:
Guardian’s Name: Guardian’s Home #:
Guardian’s Cell #:
Guardian’s Employer: Guardian’s Work #:
Guardian’s Relationship to Member:
------
Which Parent/Guardian should be listed as Head of Household?
In case of an Emergency: Emergency Contact Name Emergency Contact #
Member Allowed to Leave the Club on Their Own? NO ______YES______
Adults Authorized to Pick Up Member (First and Last Name):
BGCCA Membership Application PAGE 1 of 2
MEDICAL INFORMATION
Indicate Any Medical Problems and/or Allergies: ______
GENERAL INFORMATION
Can Member Swim: ______Yes ______No
ATTN PARENTS/GUARDIANS: Would you be interested in Volunteering at BGCCA: ______YES ______NO
PERMISSIONS
FIELD TRIPS:
______I DO give permission for my child to attend the off-site field trips with BGCCA staff supervision and, when necessary, transported by River Cities Public Transit. Transportation fee paid by BGCCA.
______I DO NOT give permission for my child to attend the off-site field trips.
National BGCA Programs:
______I DO give permission for my child to participate in BGCA National Programs:
SMART Moves, Triple Play, Power Hour, and National Youth Outcome Initiative.
______I DO NOT give my permission for my child to participate in BGCA National Programs:
SMART Moves, Triple Play, Power Hour, and National Youth Outcome Initiatives.
For more information on the Programs, contact Club Director.
CONFIDENTIAL INFORMATION
The following information is necessary for our records and funding our organization receives. The answers you provide are confidential and will be used for statistical information only. Your cooperation in providing this information is appreciated and essential to our Club.
Annual Household Income: _____ $0 to 5,000 _____ $5,001 to $10,000 _____ $10,001 to $15,000 _____$15,001 to $20,000
_____ $20,001 to $25,000 _____ $25,001 to $30,000 _____ $30,001 to $40,000 _____ $40,001 and above
# of people in Household: ______
Circle All That Apply:
SSDI SSI TANF Food Stamps Medicaid/Medicare Reduced School Lunch General Assistance
Child’s Family Setting (Household):
Single Parent Family (Mother only/Father only) Joint Custody Foster Care 1 Parent/1 Step 2 Parent Family Grandparents
Other ______
______
Parent/Guardian Signature Member Signature Date
BGCCA MEMBERSHIP APPLICATION PAGE 2 OF 2
Membership Application must be accompanied
by attached 2012-2013 Parental/Guardian Release Form.