Club Membership Registration Form

Youth Membership Application

Confidentiality. Any confidential information requested is for our records and for the funding our organization receives. The answers you provide will be kept completely confidential. Your cooperation in providing this information is both appreciated and necessary. Required fields are denoted with and asterisks (*)
Member Information
Member Name *

First Name Last Name
Member Birth Date: *

Month Day Year

Member Address: *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Home Phone Number

Area Code Phone Number
Member Gender *

Male Female
Member Ethnicity

White Black Asian Latino Native American Prefer not to answer
Membership Type

After School
Member School
Member Grade
Member Medical Information
Insurance Company
Policy Number
Primary Doctor Name
Primary Doctor Phone Number
Medications
Medical Concerns/Allergies
Medical Consent Statement

I hereby consent to any medical care and the administration of anesthesia determined by a physician to be necessary for the welfare of my child, listed on this application, while said child is under the care of the West Cook County Youth Club.
Type a question *

Clear
DateTime
Parent/Guardian Information
Parent/Guardian #1
Guardian 1 Name *

First Name Last Name

Guardian 1Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Guardial 1 Phone Number *

Area Code Phone Number
Guardian 1 Email
example@example.com
Guardian 1 Employer
Guardian 1 Occupation
Guardian 1 Relationship to Member *
Parent/Guardian #2
Guardian 2 Name

First Name Last Name

Guardian 2 Address

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Guardian 2 Phone Number

Area Code Phone Number
Guardian 2 Email
example@example.com
Guardian 2 Employer
Guardian 2 Occupation
Guardian 2 Relationship to Member
Emergency Contacts

Please list the details for any additional emergency contacts besides the parent/guardian listed above.
Emergency Contact 1

First Name Last Name
Emergency Contact 1 Phone Number

Area Code Phone Number
Emergency Contact 2

First Name Last Name
Emergency Contact 2 Phone Number

Area Code Phone Number
Household Information
Family Income

$9,000 or below $9,001-$12,000 $12,001-$15,000 $15,001-$19,000 $19,001-$23,000 $23,001-$28,000 $28,001-$33,000 $33,001-$38,000 $38,001-$42,000 $42,000 and above
Family Size
Membership Rules
*

I have read the parent/member handbook and understood, and accepted the rules for membership and request that my son/daughter be admitted for membership. I understand that the West Cook County Youth Club has an open door policy and that members are free to come and go as they choose. I have explained the rules to my son/daughter and agree that the West Cook County Youth Club will not be responsible for any accidents to my while on West Cook County Youth Club premises or while engaged in any of the activities away from the West Cook County Youth Club. I give my consent for photographs, in which my son/daughter may appear, to be used in any way the West Cook County Youth Club may care to use them.
Click Here to read Parent/Member Handbook
Parent Signature *

Clear
Member Signature *

Clear
Date/Time
After you submit your application, please ensure you make your payment at this website: www.wccyouthclub.com/become-a-member.

Thank you!
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Youth Membership Application

Member Information

Member Medical Information

Parent/Guardian Information

Emergency Contacts

Household Information

Membership Rules