BGC OF EAST MISSISSIPPI

BGC OF EAST MISSISSIPPI

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

WEST ENDNORTHEASTVELMA YOUNGSOUTHEASTNESHOBAOPRAHWALNUT GROVECARTHAGE
WHAT SESSION WILL YOUR CHILD BE ATTENDING DURING THE YEAR 2018*

FALLSPRINGSUMMER
MUST PROVIDE BIRTH CERTIFICATE IF CHILD IS 5 OR 6 YEARS OF AGE

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PARENT/GUARDIAN

First NameLast Name
DATE APPLICATION SUBMITTED

MonthDayYear
Date
CHILD NAME*

First NameMiddle NameLast Name
CHILD NICKNAME
LEAVE BLANK IF NOT APPLICABLE
GENDER*

MALEFEMALE
ETHNICITY

ASIANNATIVE AMERICANHISPANICAFRICAN AMERICANPACIFIC ISLANDEROTHER
CHILD DATE OF BIRTH

MonthDayYear
Date
CHILD AGE
WHAT GRADE IS YOUR CHILD IN?
K - 12TH GRADE
ADDRESS

Street Address

Street Address Line 2

CityState / Province

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

Area CodePhone Number
CELL PHONE

Area CodePhone Number
WORK PHONE

Area CodePhone Number
MEDICAL INFORMATION

PLEASE COMPLETE THIS SECTION
DOCTORS NAME

First NameLast Name
DOCTORS PHONE NUMBER

Area CodePhone Number
DATE OF LAST EXAM

MonthDayYear
Date
PERMISSION OF TREATMENT BY DOCTOR OR HOSPITAL IN CASE OF EMERGENCY

YESNO
MEDICAID

YESNO
SERIOUS HEALTH PROBLEMS

YESNO
IF YES, PLEASE EXPLAIN IN DETAIL
MEDICATION TAKEN

YESNO
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

YESNO
MY CHILD/CHILDREN MAY PARTICIPATE IN ALL BGC ACTIVITIES IN OR ADJACENT TO THE CLUB BUILDING

YESNO
I UNDERSTAND THAT THERE MAY BE EXPENSES RELATED TO SOME FIELD TRIPS

YESNO
MY CHILD/CHILDREN HAVE PERMISSIONS TO BE USED IN MEDIA OR PUBLIC RELATION MATERIALS.

YESNO
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*

Clear
YOUR ELECTRONIC SIGNATURE WILL SERVE AS CONSENT
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?

YESNO
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?

YESNO
IS THERE A MEMBER OF THE HOUSEHOLD HANDICAPPED?

YESNO
CURRENT HEAD OF HOUSEHOLD

MALEFEMALEBOTH
CURRENT SINGLE PARENT HOME?

YESNO
NUMBER OF HOUSEHOLD MEMBERS INCARCERATED?
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First NameLast Name
HOME PHONE NUMBER

Area CodePhone Number
CELL PHONE NUMBER

Area CodePhone Number
WORK PHONE NUMBER

Area CodePhone Number
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First NameLast Name
HOME PHONE NUMBER

Area CodePhone Number
CELL PHONE NUMBER

Area CodePhone Number
WORK PHONE NUMBER

Area CodePhone Number
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First NameLast Name
HOME PHONE NUMBER

Area CodePhone Number
CELL PHONE NUMBER

Area CodePhone Number
WORK PHONE NUMBER

Area CodePhone Number
MEMBER PICK UP CONTACT INFORMATION/PERSON AUTHORIZED TO PICK UP MEMBER

First NameLast Name
HOME PHONE NUMBER

Area CodePhone Number
CELL PHONE NUMBER

Area CodePhone Number
WORK PHONE NUMBER

Area CodePhone Number
Should be Empty:

BGC OF EAST MISSISSIPPI

MEDICAL INFORMATION

PERMISSION FORM