BGC OF EAST MISSISSIPPI

BGC OF EAST MISSISSIPPI

MEMBERSHIP APPLICATION FORM PLEASE FILL ALL REQUIRED FIELDS
SELECT YOUR CHILD'S CLUB LOCATION

WEST END NORTHEAST VELMA YOUNG SOUTHEAST NESHOBA OPRAH WALNUT GROVE CARTHAGE
WHAT SESSION WILL YOUR CHILD BE ATTENDING DURING THE YEAR 2018 *

FALL SPRING SUMMER
MUST PROVIDE BIRTH CERTIFICATE IF CHILD IS 5 OR 6 YEARS OF AGE

Browse Files
SCAN DOCUMENT AND UPLOAD HERE Cancel of
PARENT/GUARDIAN

First Name Last Name
DATE APPLICATION SUBMITTED

Month Day Year
Date
CHILD NAME *

First Name Middle Name Last Name
CHILD NICKNAME
LEAVE BLANK IF NOT APPLICABLE
GENDER *

MALE FEMALE
ETHNICITY

ASIAN NATIVE AMERICAN HISPANIC AFRICAN AMERICAN PACIFIC ISLANDER OTHER
CHILD DATE OF BIRTH

Month Day Year
Date
CHILD AGE
WHAT GRADE IS YOUR CHILD IN?
K - 12TH GRADE
ADDRESS

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
SCHOOL ATTENDING
EMAIL ADDRESS
example@example.com
HOME PHONE

Area Code Phone Number
CELL PHONE

Area Code Phone Number
WORK PHONE

Area Code Phone Number
MEDICAL INFORMATION

PLEASE COMPLETE THIS SECTION
DOCTORS NAME

First Name Last Name
DOCTORS PHONE NUMBER

Area Code Phone Number
DATE OF LAST EXAM

Month Day Year
Date
PERMISSION OF TREATMENT BY DOCTOR OR HOSPITAL IN CASE OF EMERGENCY

YES NO
MEDICAID

YES NO
SERIOUS HEALTH PROBLEMS

YES NO
IF YES, PLEASE EXPLAIN IN DETAIL
MEDICATION TAKEN

YES NO
IF YES, PLEASE EXPLAIN IN DETAIL
PERMISSION FORM

FILL REQUIRED FIELDS
MY CHILD/CHILDREN HAVE PERMISSION TO GO ON ANY FIELD TRIPS SPONSORED BY BGC OF EAST MISSISSIPPI

YES NO
MY CHILD/CHILDREN MAY PARTICIPATE IN ALL BGC ACTIVITIES IN OR ADJACENT TO THE CLUB BUILDING

YES NO
I UNDERSTAND THAT THERE MAY BE EXPENSES RELATED TO SOME FIELD TRIPS

YES NO
MY CHILD/CHILDREN HAVE PERMISSIONS TO BE USED IN MEDIA OR PUBLIC RELATION MATERIALS.

YES NO
DISCLAIMER:

The Boys & Girls Clubs of East Mississippi is not responsible or liable in any way in the event of harm or injury occurring to the member. It is agreed that the parent/guardian will not hold the Boys & Girls Clubs of East Mississippi responsible for the welfare or whereabouts of the member. If the parent or guardian does file a complaint against the Club, the parent or guardian agrees to pay the Boys & Girls Clubs of East Mississippi's legal fees.
MEDICAL PERMISSION:

If I cannot be reached, the Boys & Girls Clubs of East Mississippi has my permission to secure the most ready available medical services, and if necessary, have my child transported to the nearest emergency medical care facility. I understand that I will be responsible for any cost related to actions taken.
PARENT/GUARDIAN SIGNATURE *
PRINT NAME
SIGNATURE *

YOUR ELECTRONIC SIGNATURE WILL SERVE AS CONSENT Clear
HOUSEHOLD INFORMATION: *NOTE: This information is collected for grant writing purposes ONLY
MEMBER LIVES WITH: *
IF OTHER, LIST INDIVIDUAL NAME AND RELATIONSHIP
NAME AND RELATIONSHIP
DO YOU RESIDE IN A HOUSING DEVELOPMENT?

YES NO
IF YES, LIST THE NAME OF HOUSING DEVELOPMENT
ANNUAL INCOME $0 - $30,000.00

$0 - $5,000 $5,001 - $10,000 $10,001 - $15,000 $15,001 - $20,000 $20,001 - $25,000 $25,001 - $30,000
ANNUAL INCOME $30,001 - $60,000

$30,001 - $35,000 $35,001 - $40,000 $40,001 - $45,000 $45,001 - $50,000 $50,001 - $65,000 $65,001 - $70,000
ANNUAL INCOME $60,001 - $90,000

$60,001 - $65,000 $65,001 - $70,000 $70,001 - $75,000 $75,001 - $80,000 $80,001 - $85,000 $85,001 - $90,000
NUMBER OF FAMILY MEMBERS 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

MALE FEMALE BOTH
CURRENT SINGLE PARENT HOME?

YES NO
NUMBER OF HOUSEHOLD MEMBERS INCARCERATED?
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First Name Last Name
HOME PHONE NUMBER

Area Code Phone Number
CELL PHONE NUMBER

Area Code Phone Number
WORK PHONE NUMBER

Area Code Phone Number
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First Name Last Name
HOME PHONE NUMBER

Area Code Phone Number
CELL PHONE NUMBER

Area Code Phone Number
WORK PHONE NUMBER

Area Code Phone Number
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First Name Last Name
HOME PHONE NUMBER

Area Code Phone Number
CELL PHONE NUMBER

Area Code Phone Number
WORK PHONE NUMBER

Area Code Phone Number
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First Name Last Name
HOME PHONE NUMBER

Area Code Phone Number
CELL PHONE NUMBER

Area Code Phone Number
WORK PHONE NUMBER

Area Code Phone Number
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BGC OF EAST MISSISSIPPI

MEDICAL INFORMATION

PERMISSION FORM