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MEMBERSHIP APPLICATION Ulbrich Boys & Girls Club $30.00 per year Membership Fee 1st Member First Name: ____________________ Middle: ________________ Last: ______________________________ Nickname: _______________________ Gender: ___M ___F DOB: ____________ SSN: __________________ Ethnicity: (Circle One) African American Caucasian Native American Asian American Hispanic Puerto Rican Mexican Multi-Racial Other School Information: Current Teacher: _________________________________ School: _____________________________________ Grade: _____ Medical Information Serious Health Problems: ___Yes ___No If Yes, explain: ________________________________________ Medications: ___Yes ___No If Yes, explain: _________________________________________ Date Medical Info Received: ____________________ 2nd Member First Name: ____________________ Middle: ________________ Last: ______________________________ Nickname: _______________________ Gender: ___M ___F DOB: ____________ SSN: __________________ Ethnicity: (Circle One) African American Caucasian Native American Asian American Hispanic Puerto Rican Mexican Multi-Racial Other School Information: Current Teacher: _________________________________ School: _____________________________________ Grade: _____ Fee Level: ______________________ Medical Information Serious Health Problems: ___Yes ___No If Yes, explain: ________________________________________ Medications: ___Yes ___No If Yes, explain: _________________________________________ Date Medical Info Received: ____________________ 3rd Member First Name: ____________________ Middle: ________________ Last: ______________________________ Nickname: _______________________ Gender: ___M ___F DOB: ____________ SSN: __________________ Ethnicity: (Circle One) African American Caucasian Native American Asian American Hispanic Puerto Rican Mexican Multi-Racial Other School Information: Current Teacher: _________________________________ School: _____________________________________ Grade: _____ Fee Level: ______________________ Medical Information Serious Health Problems: ___Yes ___No If Yes, explain: ________________________________________ Medications: ___Yes ___No If Yes, explain: _________________________________________ Date Medical Info Received: ____________________ General Information Address: ___________________________________________________________________________________ City: _______________________________ State: _________ Zip: ________________ Phone: ___________________ Cell: ___________________ Email: ________________________________ Father’s First Name:____________________ Father’s Last Name: _____________________________________ Father’s Employer:______________________________________ Father’s Work Phone:___________________ Mother’s First Name:____________________ Mother’s Last Name:___________________________________ Mother’s Employer:_____________________________________ Mother’s Work Phone:___________________ Doctor/Insurance Information: Doctor Name: _____________________________ Doctor Phone: _________________________ Permission for Treatment by Doctor/Hospital: ____Yes ____No Medicaid: ____Yes ____No Does your family have health and/or accident insurance: ____Yes ____No Insurance Carrier: _____________________________________________ Policy #: ___________________________________ Group#: ___________________________________ Date Health Info Received: ____________________ Household: NOTE: This information is collected for Grant writing purposes ONLY Member lives with: ___Mom ___Step Mom ___Dad ___Step Dad ___Grandparent ___Other: __________ Number in Household: _________________ Is there a Member of the Household 65 years old or Older: ____Yes ____No Is there a Member of the Household Handicapped: ____Yes ____No Current Head of Household: ____Female ____Male Current Single Parent: ____Yes ____No
Check all that apply: ____ SSDI ____ Food Stamps ____ SSI ____ TANF ____ Food Stamps ____ General assistance ____ School Lunch ____ Care 4 Kids Programs: School Year: ___ Van Pick Up:___ Summer Camp:___ Travel Basketball:____________ General: Member/Contacts Understood Signed Insurance Disclaimer and Permission Statement: ____Yes ____No Member has permission to be used in public relations materials: ____Yes ____No Member may participate in all Club activities in or adjacent to the club building: ____Yes ____No Disclaimer: I, the parent/guardian of the minor child listed on this application, for ourselves our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Ulbrich Boys & Girls Club, and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations or participants in activities of said organizations either at or away from the Club. Medical Treatment I give permission to the Ulbrich Boys & Girls Club 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. Technology As a member of the Ulbrich Boys & Girls Club, your child will have access to the Internet. While precautions are being taken, it is possible that s/he may access inappropriate sites. The Ulbrich Boys & Girls Club will have rules and consequences at the Club for such behavior: however we will not be responsible for the consequences of such access. Miscellaneous I understand that the Ulbrich Boys & Girls Club is not responsible for lost or stolen times. I give permission for my child’s or children’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Ulbrich Boys & Girls Club and its activities. I also understand that the Club is not, nor claims to be, a licensed day care center. I have read the completed application and this form, understand the rules of the Ulbrich Boys & Girls Club and request that my child or children be admitted into membership. Contact’s Signature: ________________________ Member’s Signature: ___________________________
FOR OFFICE USE ONLY Membership #: _______________________ Entry Date: ______________ Expiration Date: ____________________ Status: _________________ Type: ________________ New/Renewal Member: _________________ Processed by: ____________
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