Annual Teen Membership Application Form

Important: Additional children at the same location can be added using the same application. If you have children at more than one location or household they must be submitted on separate applications.
Select a Location:*
- Club at the Y (TEENS 6th-12th grade)
How many children are you applying for this location?*
Member Information
Child Name:*
First Last
Age:*
Birth Date:*
MM slash DD slash YYYY
Primary Home Address:*
Street Address Address Line 2 City State ZIP Code
Gender:*
- Male
- Female
- Other
Specify
Race:*
Ethnicity:*
Who does the child live with?*
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable):
ie, Parent's Boyfriend/Girlfriend
School Information
School Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:*
- Free
- Reduced
- Neither
- Prefer not to answer
Does your child have an individual Education Plan (IEP) or a 504 Plan?*
- Yes
- No
- Prefer not to answer
Are you applying for fee assistance?*
- Yes
- No
- N/A
Explain Special Circumstances:*
(provide important information regarding any sudden income loss or financial hardship)
Medical Information
Check all medical conditions your child experiences:*
If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
- ADHD/ADD
- ANXIETY
- ODD
- DEPRESSION
- AUTISM
- HEARING IMPAIRMENT
- SEIZURES
- ASTHMA
- DIABETES
- Other
- None
- Prefer not to answer
Please explain:*
Does your child have any allergies?*
- Yes
- No
- Prefer not to answer
List all allergies:*
Does your child have an Epi Pen?*
- Yes
- No
- Prefer not to answer
Does your child take any medications?*
- Yes
- No
- Prefer not to answer
List all medications:*
Child 2 - Member Information
Child Name:*
First Last
Primary Home Address:*
Street Address Address Line 2 City State ZIP Code
Age:*
Birth Date:*
MM slash DD slash YYYY
Gender:*
- Male
- Female
- Other
Specify
Race:*
Ethnicity:*
Who does child 2 live with?*
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable):
ie, Parent's Boyfriend/Girlfriend
Child 2 - School Information
School Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:*
- Free
- Reduced
- Neither
- Prefer not to answer
Does your child have an individual Education Plan (IEP) or a 504 Plan?*
- Yes
- No
- Prefer not to answer
Are you applying for fee assistance?*
- Yes
- No
- N/A
Child 2 - Medical Information
Check all medical conditions child 2 experiences:*
If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
- ADHD/ADD
- ANXIETY
- ODD
- DEPRESSION
- AUTISM
- HEARING IMPAIRMENT
- SEIZURES
- ASTHMA
- DIABETES
- Other
- None
- Prefer not to answer
Please explain:*
Does child 2 have any allergies?*
- Yes
- No
- Prefer not to answer
List all allergies:*
Does your child have an Epi Pen?*
- Yes
- No
- Prefer not to answer
Does child 2 take any medications?*
- Yes
- No
- Prefer not to answer
List all medications:*
Child 3 - Member Information
Child Name:*
First Last
Primary Home Address:*
Street Address Address Line 2 City State ZIP Code
Age:*
Birth Date:*
MM slash DD slash YYYY
Gender:*
- Male
- Female
- Other
Specify
Race:*
Ethnicity:*
Who does child 3 live with?*
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable):
ie, Parent's Boyfriend/Girlfriend
Child 3 - School Information
School Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:*
- Free
- Reduced
- Neither
- Prefer not to answer
Does your child have an individual Education Plan (IEP) or a 504 Plan?*
- Yes
- No
- Prefer not to answer
Are you applying for fee assistance?*
- Yes
- No
- N/A
Child 3 - Medical Information
Check all medical conditions child 3 experiences:*
If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
- ADHD/ADD
- ANXIETY
- ODD
- DEPRESSION
- AUTISM
- HEARING IMPAIRMENT
- SEIZURES
- ASTHMA
- DIABETES
- Other
- None
- Prefer not to answer
Please explain:*
Does child 3 have any allergies?*
- Yes
- No
- Prefer not to answer
List all allergies:*
Does your child have an Epi Pen?*
- Yes
- No
- Prefer not to answer
Does child 3 take any medications?*
- Yes
- No
- Prefer not to answer
List all medications:*
Child 4 - Member Information
Child Name:*
First Last
Primary Home Address:*
Street Address Address Line 2 City State ZIP Code
Age:*
Birth Date:*
MM slash DD slash YYYY
Gender:*
- Male
- Female
- Other
Specify
Race:*
Ethnicity:*
Who does child 4 live with?*
Explain:*
Parent/Guardian Name:*
Additional Adult in Household (if applicable):
ie, Parent's Boyfriend/Girlfriend
Child 4 - School Information
School Grade:*
School Name:*
Primary Teacher Name:*
School Lunch Program:*
- Free
- Reduced
- Neither
- Prefer not to answer
Does your child have an individual Education Plan (IEP) or a 504 Plan?*
- Yes
- No
- Prefer not to answer
Are you applying for fee assistance?*
- Yes
- No
- N/A
Child 4 - Medical Information
Check all medical conditions child 4 experiences:*
If families choose not to disclose a health condition, staff still must respond, but the response may be tempered.
- ADHD/ADD
- ANXIETY
- ODD
- DEPRESSION
- AUTISM
- HEARING IMPAIRMENT
- SEIZURES
- ASTHMA
- DIABETES
- Other
- None
- Prefer not to answer
Please explain:*
Does child 4 have any allergies?*
- Yes
- No
- Prefer not to answer
List all allergies:*
Does your child have an Epi Pen?*
- Yes
- No
- Prefer not to answer
Does child 4 take any medications?*
- Yes
- No
- Prefer not to answer
List all medications:*
Parent/Guardian Information
All parents/guardians listed are allowed to pick-up the child(ren) named above unless access is prohibited or restricted by a court order (provided to Club).
Primary Parent/Guardian:*
First Last
Relationship to Member:*
Home Address:*
Street Address Address Line 2 City State ZIP Code
Primary Phone:*
Primary Phone Type:*
Secondary Phone: (optional)
Secondary Phone Type: (optional)
Email Address:*
Employer:*
Household Income*
Number in Household:*
Other Parent/Guardian (optional)
Full Name:
First Last
Relationship to Member:
Home Address:
Street Address Address Line 2 City State ZIP Code
Primary Phone:
Primary Phone Type:
Secondary Phone:
Secondary Phone Type:
Email Address:
Employer:
Military Involvement
Is/Was either parent/guardian in the Armed Forces?*
- Yes
- No
Branch:*
Emergency Contact/Authorized Pick Up
Must be someone OTHER THAN PARENT/GUARDIAN.
Contact #1:*
First Last
Relationship to Member:*
Primary Phone:*
Primary Phone Type:*
Contact #2:*
First Last
Relationship to Member:*
Primary Phone:*
Primary Phone Type:*
YOUTH ONLY: Option for Authorized Pick-up*
You can choose to require that your child only be allowed to leave the Club under the supervision of individuals you have authorized by selecting ‘yes’ to the authorized pick up option. Only contacts listed on this application or the Authorized Pick Up form, will be allowed to pick up your child from the Club. These contacts will be verified at time of pick up. Or you can choose to allow your child to walk home from the after school program. Specific communications will be required for Club staff to release your child to walk home should you select this option. These requirements will be communicated by the Unit Director. **Please contact BGC staff if alternate transportation methods are required.
- YES I am selecting authorized pick up.
- I am allowing my child to walk home from the after school program.
Policy and Waiver Information
PLEASE READ CAREFULLY
OPEN DOOR POLICY:
I understand the Boys & Girls Clubs of Sheboygan County has an “open door policy”. It is my responsibility as the parent/guardian to instruct my child as to whether or not he/she may leave the Club.
PROGRAM COMMUNICATIONS:
The Boys & Girls Clubs of Sheboygan County uses the Remind app to communicate important messages about the program and arrival for pick up daily. I agree to receive these text message/email notifications & use Remind to notify the Club when pick up has arrived for your child.
MEDICAL EMERGENCY:
In the event of an emergency, I understand that every attempt will be made to contact me. If I cannot be reached, I hereby give my permission to the physician selected by the Boys & Girls Club staff to secure proper treatment for my child.
Liability:
I understand that the Boys & Girls Clubs of Sheboygan County is not responsible or liable in any way in the event of harm or injury occurring to my child. It is agreed that I will hold the Boys & Girls Clubs of Sheboygan County harmless for the actions of my children or the action of other children that result in the harm of others or damage to property, including activities outside of the Club.
PHOTOS/VIDEOS:
I give consent for photographs, videos, artwork and/or like materials, in which my child may appear, to be used in any promotional materials the Boys & Girls Club may care to use them. I understand it is my responsibility to inform the director, in writing, if my child cannot be in photographs, videos, artwork, and/or like materials.
LATE PICK-UP POLICY:
I understand my child cannot be left at the Boys & Girls Club earlier than the Club’s established hours of operation and my child must leave the Club’s property or be picked up at or before closing time. I understand that I will be charged a fee for late pick up. I understand that if my child(ren) remains at the Club and the Club does not receive any communication within 30 minutes after closing, the police will be contacted.
TRAVEL:
I authorize my child to participate in walking field trips, under proper staff supervision, within the local city limits. No additional permission slips will be required for walking trips.
PROGRAM PARTICIPATION:
I understand that my child will be participating in activities scheduled for his/her group and that participation is required. I understand my child’s participation is based on his/her ability to follow expectations of the Club and to respect staff, property and other Club members. Membership may be suspended or terminated at any time for misbehavior without a refund of fees.
DATA COLLECTION & SHARING:
I give permission to the Boys & Girls Clubs of Sheboygan County to use this membership information provided, as well as information obtained via surveys and questionnaires, to compile aggregate results that may be shared with Club staff, Boys & Girls Clubs of America, funders, school districts and other community stakeholders to assess and communicate program effectiveness and Club impact. I understand that my child’s responses will remain confidential. Included in, but not limited to these surveys are: NYOI survey, individual program surveys (SMART Moves, SMART Girls, Passport to Manhood, etc.)
SCHOOL INFORMATION:
I give permission to the Boys & Girls Clubs of Sheboygan County and the member’s school district to exchange information regarding the minor child listed on this application.
TECHNOLOGY:
As a member of the Boys & Girls Club, your child will have access to the internet and electronic devices designed for educational and enrichment programming. Precautions have been taken to maintain a safe electronic presence here at the Club, however it is impossible for the Boys & Girls Club to restrict access to all controversial materials. I will not hold the Boys & Girls Club responsible for unintentional exposure to such material while on the internet. I understand that my child is expected to follow all technology expectations of the Club, as listed in the parent handbook. I accept full responsibility for all intentional harm caused by my child to computer resources of the Boys & Girls Clubs of Sheboygan County or any other affected parties.
I HEREBY CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION.
I hereby certify that all above information is true, accurate and complete to the best of my knowledge. I am also aware that it is my responsibility to notify the Boys & Girls Clubs of Sheboygan County of any change of information.
Parent/Guardian Signature:*
Signer's Printed Name:*
First Last
Signed Date:*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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Annual Teen Membership Application Form

Member Information

School Information

Medical Information

Child 2 - Member Information

Child 2 - School Information

Child 2 - Medical Information

Child 3 - Member Information

Child 3 - School Information

Child 3 - Medical Information

Child 4 - Member Information

Child 4 - School Information

Child 4 - Medical Information

Parent/Guardian Information

Other Parent/Guardian (optional)

Military Involvement

Emergency Contact/Authorized Pick Up

Policy and Waiver Information

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