Membership Application Form

Member’s Contact Information: (Please Print)

First Name:_________________________________ Middle Name: ____________________________ Last Name: _________________________________

Primary Guardian: ________________________________________________________ Member’s Cell: _____________________________ Text: Y / N

Home Address: ____________________________________________________ City: __________________________ State: ______ Zip Code: __________

Parents/Guardians Contact Information:

Mother/Guardian’s Name: ________________________________________________ Cell: __________________________________ Text: Y / N

Employer: _______________________________________ Occupation: ____________________________ Work #: ______________________________

Address: (If Different From Child) ________________________________________________________ Email: _________________________________________

Father/Guardian’s Name: _________________________________________________ Cell: __________________________________ Text: Y / N

Employer: _______________________________________ Occupation: ____________________________ Work #: ______________________________

Address: (If Different From Child) ________________________________________________________ Email: _________________________________________

Emergency Contact/Alternate Pick-Up: (Other Than Parent)

First Name: __________________________________ Last Name: __________________________________ Relationship to Child: _____________________

Address: ______________________________________________ City: _____________________________ State: _______ Zip Code: __________________

Emergency Phone: ______________________________ Email: _________________________________________________ Sex: M / F

Member Demographic Information:

Sex: M / F Birthdate: ______/______/______ Current Age: ________ Current Grade: ________ Name of School: ________________________________

Ethnicity: (Please Check One)

African American Arab Asian Caucasian Hispanic Multi-Ethnic Native American Other: ________________________

Boys & Girls Club You Are Joining: KidsCare Site You Are Joining:

Elkhart Goshen

Middlebury Nappanee

Cleveland Eastwood

Mary Feeser Hawthorne

Pinewood Riverview

Woodland Chandler

Concord Inter. Orchard View

Mary Daly Nappanee Club

Membership:

New Renewing

# of yrs as a member

________

Household Structure:

Two Parent Foster Parents

Mother Only Guardianship

Father Only Grandparents

1 Parent/ 1 Step

Total # In

Household:

________

102 W. Lincoln Ave., Ste 240 PO Box 614, Goshen, IN 46527

P: 574.534.5933 | F: 574.537.1925 bgcelkhartcounty.org

59197 CR 13 Elkhart, IN 46517 P: 574.830.0311 | F: 574.830.0317

bgckidscare.org

FOR OFFICE USE ONLY:

Date Recvd: __________ YES Entry: ________ Receipt #: __________ Scholarship: ______________

Staff Int.: __________ Staff Int.: ________ Check #: __________ (Staff Initials)

School Year: __________ Cash: $__________ Member ID: ______________

Pd by CC: ___________

KIDSCARE START DATE: ___________________ (Must Be Submitted 48 Business Hours Before Start Date)

MEDICAL/HEALTH HISTORY:

CONFIDENTIAL: The following information is necessary for our records and the funding our organization receives. The answers you provide are

completely confidential. Your cooperation in providing this information is both appreciated and necessary.

Gross Household Income: (Please Check One)

Under $9,000 $19,001 - $23,000 $38,001 - $42,000

$9,001 - $12,000 $23,001 - $28,000 $42,001 - $45,000

$12,001 - $15,000 $28,001 - $33,000 Over $45,001

$15,001 - $19,000 $33,001 - $38,000

Allergies: (Please List All Known - Including Food Allergies)

__________________________________________

__________________________________________

__________________________________________

Describe Reaction and Management of the Reaction: (Please Be As Detailed As Possible)

______________________________________________________________________

______________________________________________________________________

______________________________________________________________________

Medications Being Taken: (NOTE: MEDICATIONS WILL NOT BE DISPENSED BY STAFF)

My Child Takes NO Medications On A Routine Basis

My Child Takes Medications As Follows:

Med #1: _____________________________ Dosage: _____________________ Specific Times Taken Each Day: ________________

Med #2: _____________________________ Dosage: _____________________ Specific Times Taken Each Day: ________________

Med #3: _____________________________ Dosage: _____________________ Specific Times Taken Each Day: ________________

Please Mark If Your Child Has Any of the Following

Health Conditions:

Asthma Epilepsy Diabetes

Convulsions Upset Stomach Fainting

Heart Problems Frequent Headaches

Assisted Programs - Federal and/or State Funded: (Please Check All That Apply)

Food Stamps Medicare

Free/Reduced Lunch SSI

Medicaid TANF

Please Describe Any Other Medical Needs, Physical/Mental Health Issues, and/or Any Other Disabilities:

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________

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 Boys & Girls Club of Elkhart County, Boys & Girls Club of Goshen, Boys & Girls Club of Middlebury, Boys & Girls Club of Elkhart, Boys & Girls Club of Nappanee, KidsCare A Division of the Boys & Girls Clubs of Elkhart County, 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 participation in activities of said organizations either at or away from the Club.

I give permission to the Boys & Girls Club to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any and all costs of medical attention and treatment.

I give my permission to the Boys & Girls Clubs of Elkhart County and to Elkhart Community Schools and/or Concord Community Schools and/or Wa-Nee Community Schools and/or Middlebury Community Schools and/or Goshen Community Schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Club, and in life. This release is valid for one year and may be revoked at any time by contacting Elkhart, Concord, Wa-Nee, Middlebury, and/or Goshen Community Schools or the Boys & Girls Club in writing.

I give my consent for photographs in which my child may appear to be used in any way the Boys & Girls Club may care to use them.

I understand that the Boys & Girls Club is not responsible for lost or stolen items.

I have read the completed application, answered all questions to the best of my ability and with all honesty to the best of my knowledge. I understand the rules of the Boys & Girls Club and request that my child be admitted into membership.

__________________________________________________________________ ________/________/________

Parent/Guardian Signature Date

__________________________________________________________________ ________/________/________

Member Signature Date

Please Mark If Your Child Has Any of the Following

IEP/504 Plan (If yes, please describe below)

Autism ADD/ADHD One-on-One Needs

Visual/Hearing Needs Oppositional Defiant Disorder

Other: ___________________________________________