MEMBERSHIP ENROLLMENT FORM

BOYS & GIRLS CLUBS OF GREATER WASHINGTON

2012 Enrollment Year

MEMBER (CHILD) INFORMATION
Last Name: / First Name: / Middle Name:
Home Address: / City: / Zip: / Birthdate:
Month: Day: Year:
Email: / Age: / Ethnicity:
African American
Asian Pacific Islander
Hispanic/Latino
 Multi - Racial
Native American
 Caucasian
Home Phone:
Cell Phone: / Gender:
Male
Female
Language Spoken At Home: / Ward (DC only):
Do you consent for your child to receive medical attention in the event of an emergency?  Yes  No
School: / Grade:
Sibling Name: Age: Member:
PARENT/GUARDIAN INFORMATION
Mother/Guardian’s Name:
Home Address: Home Phone: Cell Phone:
E-mail Address:
Employer: Job Title:
Work Address: Work Phone:
Military Branch: Status: Start Date: End Date:
Father/Guardian’s Name:
Home Address: Home Phone: Cell Phone:
E-mail Address:
Employer: Job Title:
Work Address: Work Phone:
Military Branch: Status: Start Date: End Date:
This information is used only to seek funding for programs: Check all that apply
TANF
Free/Reduced/Lunch / Membership Type: Check one:
After School ____
Summer Camp ____
Before & After ____
Holiday Camp ____
Transportation ____
Membership Fee _____
MEMBER MEDICAL INFORMATION
Medical Problems/Allergies:
Medications: Disabilities:
Special Needs:
EMERGENCY CONTACT INFORMTION
(Names not already provided)
1. First Name Last Name: Home Phone: Work: Cell:
Relationship:
2. First Name: Last Name: Home Phone: Work: Cell:
Relationship:

I have read the completed application, understand the rules of the Boys & Girls Clubs of Greater Washington and request that my son/daughter be admitted into membership.

I have explained the rules to my son/daughter and agree that BGCGW will not be responsible for any accident to my son/daughter while on BGCGW premises or while engaged in any of its activities away from BGCGW.

I give my consent for photographs or videotaping in which my son/daughter may appear, to be used in any way BGCGW may care to use them, as long as it is consistent with the BGCGW mission.

I understand that any materials made possible and/or at the Boys & Girls Clubs of Greater Washington is solely the property of the Boys & Girls Clubs of Greater Washington. This includes but not limited to recording, artwork, and written documents.

I will provide a copy of my son/daughter’s report card and if not provided I authorize BGCGW to obtain my son/daughter report card from their school.

______

Parent or Guardian’s Signature Member’s Signature Date

Version: 01032012-1