Great Futures Start Here

Membership Application

    Member Information

    Club Location:

    Gender:   MaleFemale
    Gender:
    MaleFemale
    Gender:
    MaleFemale
    Gender:
    MaleFemale
    Race:

    State:

    School Information

    Free or Reduced Lunch?
    YesNo

    Household

    NOTE: This information is collected for Grant writing purposes ONLY

    Member lives with:   MomStep MomDadStep DadGrandparentOther
    Member lives with:   MomStep MomDadStep DadGrandparentOther
    Member lives with:
    MomStep MomDadStep DadGrandparentOther
    Member lives with:
    MomStep MomDadStep DadGrandparentOther
    Does the child live in a housing development?   YesNo
    Does the child live in a housing development?   YesNo
    Does the child live in a housing development?   YesNo
    Does the child live in a housing development?
    YesNo

    Annual Income Level:
    Is there a Member of the Household 65 years old or older?   YesNo
    Is there a Member of the Household 65 years old or older?   YesNo
    Is there a Member of the Household 65 years old or older?
    YesNo
    Is there a Member of the Household 65 years old or older?
    YesNo
    Is there a Member of the Household Handicapped?   YesNo
    Is there a Member of the Household Handicapped?   YesNo
    Is there a Member of the Household Handicapped?
    YesNo
    Is there a Member of the Household Handicapped?
    YesNo
    Current Head of Household?   FemaleMale
    Current Head of Household?   FemaleMale
    Current Head of Household?
    FemaleMale
    Current Head of Household?
    FemaleMale
    Current Single Parent?   YesNo
    Current Single Parent?   YesNo
    Current Single Parent?
    YesNo
    Current Single Parent?
    YesNo

    Is the parent or guardian currently serving in the Military?   YesNo
    Is the parent or guardian currently serving in the Military?   YesNo
    Is the parent or guardian currently serving in the Military?
    YesNo
    Is the parent or guardian currently serving in the Military?
    YesNo

    Contacts

    Role:   Parent/GuardianEmergencyAuthorized to Pickup Member
    Role:   Parent/GuardianEmergencyAuthorized to Pickup Member
    Role:
    Parent/GuardianEmergencyAuthorized to Pickup Member
    Role:
    Parent/GuardianEmergencyAuthorized to Pickup Member

    Add a contact


    Disclaimer
    I do hereby give my son/daughter permission to attend and participate in activities sponsored by the Boys & Girls Clubs of the Big Bend. I hereby release the Boys & Girls Club, its Directors, employees, associates, and contributors from liability from any injury, loss, or theft incurred by my son/daughter while participating. Furthermore, I hereby authorize medical examination and emergency treatment for my son/daughter by a qualified licensed physician in the event of an accident. I do hereby give my son/daughter permission to walk home. Further, I give permission for my child's picture to be used in any Boys & Girls Club publication.

    I Agree
    By checking "I Agree", I acknowledge that I completely understand the above statement