BOYS AND GIRLS CLUBS of CENTRAL TEXAS
2019 - ANNUAL YOUTH MEMBERSHIP APPLICATION – All applications expire on 12/31/ each year.
 
MEMBERSHIP TYPE
MEMBER INFORMATION
Unit/Branch:*  
Child's Name:
(First)*

(Middle)

(Last)*
Date of Birth:*
Age Group:*
Gender:*
Ethnicity:*
Primarily Plan to Attend:*
Phone:*
Current School Attending:*
Current Grade:*
Teacher:
Based on the current school year, did your child advance a grade from the previous school year?*
Did your child have any part-time, summer or seasonal work during the past 12 months?*
Address:*
Country:*
State:*
City:*
Zip:*
Other Zip Code:*
Allow Pickup:*
Primary Guardian Email:*
HOUSEHOLD INFORMATION
PRIMARY GUARDIAN
Relationship:*
Is household member:*
Name:
First Name*

Middle Name

Last Name*
Phone:* (Atleast one should be filled)
Home#: Cell#: Work#:
Check, if Email Address is same as Primary Guardian Email Address
Email Address:*
Marital Status:*
Employer:
Check, if Address is same as Child's Address
Address:*
Country:*
State:*
City:*
Zip: *
Other Zip Code:*
SECONDARY GUARDIAN
Relationship:*
Is household member:*
Name:
First Name*

Middle Name

Last Name*
Phone:* (Atleast one should be filled)
Home#: Cell#: Work#:
Email Address:
Marital Status:*
Employer:
Check, if Address is same as Child's Address
Address:*
Country:*
State:*
City:*
Zip:*
Other Zip Code:*
HOUSEHOLD
Household Name:*
Housing Development:*
Ill, Injured or Wounded Soldier?
Military Branch:*
Lives on Military Base?*
Military Family:*
Current Head of Household:*
Single Parent: *
List number & age of siblings in household:
Sister(s)#:
ages: Brother(s)#:
ages:
How many people live in your house INCLUDING you?*
I Live With My:
Mom Step Mom Dad Step Dad
Grandparent Foster Parent(s) Other
Check, if Address is same as Child's Address
Address:*
Country:*
State:*
City:*
Zip:*
Other Zip Code:*
EMERGENCY CONTACTS
Please list additional relative and/or friend to contact in case of an emergency and your parents cannot immediately be reached.
Name:
(First)*

(Middle)

(Last)
Gender:*
Relation: Phone:*
Name:
(First)*

(Middle)

(Last)
Gender:*
Relation: Phone:*
Confidential Information
The following is necessary for our records and the funding our organization receives. The answers you provide are confidential. Your cooperation in providing this information is both appreciated and necessary.
Combined household income is:*


Does this member receive FREE lunches / Reduced price at school?*
 
HEALTH
Does your family have accident insurance?*
List all medicine child is taking:
Hospital / Doctor you use: Are you eligible for dependant medical treatment on Post?*
Special Needs/Health Issues:*
If yes explain:
Permission for treatment by doctor/hospital:*
Medication: *
If yes explain:
THE BOYS & GIRLS CLUBS OF CENTRAL TEXAS (BGCTX) DOES NOT DISPENSE OR ADMINISTER ANY MEDICATION TO MEMBERS. MEDICATION CAN ONLY BE ADMINISTERED BY THE PARENT/GUARDIAN.
Swimming Permission form/release of liability (if applicable at location)
I, the parent/guardian of the member, understand that swimming is a hazardous activity. I recognize there are risks inherent in the activity of swimming, including but not limited to
paralyzing injuries and death. The parent/guardian of the member hereby agrees to allow said member to participate in swimming activities at the Boys & Girls Club and hereby
agrees to indemnify and hold harmless the Boys & Girls Clubs of Central Texas, its directors, employees and volunteers against any liability resulting from any injury that may
occur to the member while participating in Club activities including swimming. The parent/guardian also agrees to indemnify Boys & Girls Clubs of Central Texas for any damages
incurred arising from any claims, demand, action or cause of action by the member. Further, the parent/guardian agrees to pay all costs associated with medical care. I have read
the above swimming liability release and sign it with full knowledge of its content and significance.
Authorized by parent/guardian for swimming :*
******************************************************************************* PARENT PERMISSION ******************************************************************************
My child is joining BGCTX (Boys & Girls Clubs of Central Texas) with my permission. I understand that BGCTX is an open-campus and not responsible for the time or manner in which he/she may arrive at or leave the club, BGCTX does require persons of responsibility to enter the facility before Club members sign out of the program at elementary age locations. BGCTX is not responsible for injury, death, medical expense, loss, or damage of personal property while this member is participating in club activities. If, in the opinion of BGCTX staff, my child has a medical emergency, I give my permission for him/her to be examined/treated by licensed medical personnel at my expense. An ambulance may be called if deemed necessary for transportation. I give my express permission for my child to be transported to BGCTX events by club or private transportation. By signing below, I also give my express permission for my child to be videotaped or photographed for publicity purposes. I agree to be financially responsible for any/all club equipment checked out by my child and not returned to the club in a timely manner. I agree to furnish transportation for my child to leave the club before the posted closing time for any given club day and understand that after a child/youth has been left for 30 minutes after closing time, the proper authorities will be contacted. I understand that BGCTX is a drug/alcohol free zone and that persons who violate this policy will be dealt with sternly. I understand the Club may charge additional program fees including an additional summer program fee. I understand that certain units of the Boys & Girls Clubs of Central Texas may be designated for teens only and/or for youth 7-12 or 6-18 years old (age varies by club location, please check with your club) BGCTX IS NOT A LICENSED DAYCARE. I read/have a copy of the Parent Handbook/Club Rules and will cover them with my child. If my child is suspended for any reason, I will not expect the return of any dues/fees that I have paid to the club.

Acceptable use policy for technology: I understand that my child will have access to club computer equipment and internet use and they will be held accountable for violation of the Clubs rules as stated in the Parent Handbook.

Data Collection/Sharing:
I give my permission to BGCTX to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders, and other community stakeholders for research purposes as well as evidence of program effectiveness and/or Club impact on our members. Information that will be disclosed to BGCA may include the information provided on this membership form, information provided by the minor child’s school or school district and other information collected by BGCTX, including data collected via surveys or questionnaires.

Surveys and Questionnaires: I give my permission to BGCTX to survey my child about his/her Club experiences, risk behaviors, skills, and attitudes. I give consent for my child to complete National Youth Outcomes Initiative Surveys involving questions about his/her risk behaviors at the end of the calendar year, in the spring, and the end of summer. I am aware of that blank sample copies of the NYOI surveys are available for review at the Front Desk. I agree that if I do not want my child to participate in the surveys, I must provide notice in writing to BGCTX.

School Information: I give my permission to BGCTX and your child’s school district 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 Clubs and in life. This release is valid for one year and may be revoked at any time by contacting the Boys & Girls Club in writing. I give permission for BGCTX to make and retain copies of my child’s (or ward’s) report cards and/or progress reports in order to better understand the academic needs of my child (or ward) and to better assist him/her in his/her educational pursuits. I understand that copies made of report cards and/or progress reports will remain confidential and will only be viewed by BGCTX staff.
 
Parent/Legal Guardian Name Printed:*
Date: 10/22/2019
Parent/Legal Guardian Signature:*
Member's Signature:*