Membership Application Member InformationClub Location: ---Pinewood PlaceSpringfieldSunriseMiccosukeeOakRidgeHavanaQuincyChattahoocheeOutreach Sites Gender: MaleFemaleGender: MaleFemaleGender: MaleFemaleGender: MaleFemale Race: ---African AmericanAsianLatinoHispanicNative AmericanPacific IslanderPuerto RicanSpanishWhite State: AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareWashington DCFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennslyvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming School Information Free or Reduced Lunch? YesNoHouseholdNOTE: This information is collected for Grant writing purposes ONLYMember lives with: MomStep MomDadStep DadGrandparentOtherMember lives with: MomStep MomDadStep DadGrandparentOtherMember lives with: MomStep MomDadStep DadGrandparentOtherMember lives with: MomStep MomDadStep DadGrandparentOther Does the child live in a housing development? YesNoDoes the child live in a housing development? YesNoDoes the child live in a housing development? YesNoDoes the child live in a housing development? YesNo Annual Income Level:---$0 - $5000$5000 - $10000$10000 - $15000$15000 - $20000$20000 - $25000$25000 - $30000$30000 - $35000$35000 - $40000$40000 - $45000$45000 - $50000$50000 - $55000$55000 - $60000$60000 - $65000$65000 - $70000$70000 - $75000$75000 - $80000$80000 - $85000$85000 - $90000+ Is there a Member of the Household 65 years old or older? YesNoIs there a Member of the Household 65 years old or older? YesNoIs there a Member of the Household 65 years old or older? YesNoIs there a Member of the Household 65 years old or older? YesNoIs there a Member of the Household Handicapped? YesNoIs there a Member of the Household Handicapped? YesNoIs there a Member of the Household Handicapped? YesNoIs there a Member of the Household Handicapped? YesNoCurrent Head of Household? FemaleMaleCurrent Head of Household? FemaleMaleCurrent Head of Household? FemaleMaleCurrent Head of Household? FemaleMaleCurrent Single Parent? YesNoCurrent Single Parent? YesNoCurrent Single Parent? YesNoCurrent Single Parent? YesNoIs the parent or guardian currently serving in the Military? YesNoIs the parent or guardian currently serving in the Military? YesNoIs the parent or guardian currently serving in the Military? YesNoIs the parent or guardian currently serving in the Military? YesNoContacts Role: Parent/GuardianEmergencyAuthorized to Pickup MemberRole: Parent/GuardianEmergencyAuthorized to Pickup MemberRole: Parent/GuardianEmergencyAuthorized to Pickup MemberRole: Parent/GuardianEmergencyAuthorized to Pickup Member HomeWorkAdd 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. 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
