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 NameLast Name
Member Birth Date:*

MonthDayYear
Member Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Home Phone Number

Area CodePhone Number
Member Gender*

MaleFemale
Member Ethnicity

WhiteBlackAsianLatinoNative AmericanPrefer 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 NameLast Name
Guardian 1Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardial 1 Phone Number*

Area CodePhone 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 NameLast Name
Guardian 2 Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Guardian 2 Phone Number

Area CodePhone 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 NameLast Name
Emergency Contact 1 Phone Number

Area CodePhone Number
Emergency Contact 2

First NameLast Name
Emergency Contact 2 Phone Number

Area CodePhone 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