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. 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