New Member Registration - School Closures » Boys & Girls Clubs of Benton and Franklin Counties

Step 1 of 8

Parent/Guardian Information:
First and last name of parent/guardian:*
Name of the primary parent we will interact with.
First Last
Relationship to child(ren)*
Contact Phone:*
Best phone to reach you at.
Parent/Guardian Address:*
Street Address City State ZIP Code
Email*
Employer:
Work Phone Number:
First and last name of parent/guardian:
if the child has more than one parent/guardian.
First Last
Address of second parent:
Street Address City State ZIP Code
Second parent's contact phone:
Second parent's email:
Second Parent's Employer:
Second Parent's Work Phone:
Emergency Contact #1:*
Name of an emergency contact that is the above parent(s) or guardian(s). This person will also be allowed to pick the child up.
First Last
Emergency Contact #1's Contact Phone:*
Emergency Contact #1's address*
Required by Washington State Department of Early Learning

Street Address City State ZIP Code
Emergency Contact #2:*
Name of an emergency contact that is neither of the parent/guardian(s) listed above. This contact will also be able to pick the child up.
First Last
Emergency Contact #2's Contact Phone:*
Emergency Contact #2's address*
Required by Washington State Department of Early Learning

Street Address City State ZIP Code
Additional people that may pick up child(ren):
Please provide the first and last names of other individuals that may pick up your child.
Names of any individuals NOT authorized to pick child(ren) up:
A copy of the court order is required.

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Medical Information:
Primary Physician:*
Please provide the name of the primary physician that cares for your child(ren)
Address of primary physician:*
Required by the Washington State Department of Early Learning

Street Address City State ZIP Code
Physician's Phone Number:
Dentist:*
Dentist's Address:*
Required by the Washington State Department of Early Learning

Street Address City State ZIP Code
Dentist's Phone Number:

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Please upload the additional forms here
You may upload the Certificate of Immunization form here. You may also upload forms related to parenting plans if applicable. (This can be done later, but must be done prior to child's first day.)
Drop files here or

Max. file size: 5 MB.
Annual Household Income*
This information is required for grant and reporting purposes and will be kept confidential.
Military Status of Parent(s)/Caregiver(s)?*
- Active Duty
- Reserve
- None
How did you hear about the Boys & Girls Club?
Release & Fine Print:
I agree to abide by the terms and conditions of the Boys & Girls Clubs of Benton and Franklin Counties (BGCBFC) Parent Handbook. Available upon request, is the Policies and Procedures Manual including the Health Care Plan, Pesticide Policy, Safety Management Plan and Disaster Plan (licensed programs). I agree to permit my child to participate in field trips or other activities sponsored by the BGCBFC. This permission is given with the understanding that transportation, if needed, will be provided by the BGCBFC by Club vehicle, school buses, public transportation, or other approved and regulated methods of transportation. I certify that my child is covered by medical insurance as listed on the above Membership/Emergency Form. I understand that I am solely responsible to provide such coverage. I agree to abide by all the rules of the BGCBFC pertaining to the health and safety of the members and to inform the Club immediately of any change in my child’s health, health care insurance, or medical provider. In case of serious accident or illness to my child, I hereby authorize the staff of the BGCBFC, my children’s physician, dentist, emergency personnel, and those individuals named on the Membership Form to give any necessary treatment to my child, including emergency surgery, at my expense. I understand that there is a certain amount of risk involved in even the simplest of children’s games, sports and activities, and I give permission for my child to participate in Club activities and programs. I agree that the BGCBFC, its employees, Board of Directors and affiliated agencies, shall not be liable for any claims, demands, injuries, damages, or actions to me or to my child as a result of my child’s involvement in BGCBFC programs or activities. By signing my permission below, I give permission for the BGCBFC to use photographs and other types of media of my child for promotional purposes. If I wish to revoke this permission, I will specifically request a Public Relations Denial form. I understand that the BGCBFC works with officials, staff, teachers, and other interested parties in my child’s school district for the express purpose of ensuring the Academic Success and well-being of my member. I give the BGCBFC, and its agents, permission to contact these individuals directly to discuss the attendance, grade progression, academic progress, disciplinary issues and other matters not specifically referenced of my child. I also hereby provide the School District with release to such documents that contain information regarding the learning assessment, reading level, homework status, behavior and other cognitive and skill-related determinations. BGCBFC may share information about the child(ren) listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the child’s school or school district, and other information collected by the BGCBFC. All information provided to BGCA will be kept confidential. I understand the implication of this Permission and Statement of Release. I certify that I am legally capable of executing this agreement, and that I have so of my own free will on the date indicated below, on behalf of myself, my spouse, if not signed separately, and our child for whom this form was prepared. I further certify that all information provided is the most current and understand that it is my duty to update this information should anything change.
Your Name:*
By entering your first name, last name and date, you are agreeing to the above terms. Please feel free to contact us if you have any concerns. Thank you!
First Last
Date*
MM slash DD slash YYYY
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New Member Registration – School Closures

Step 1 of 8

Parent/Guardian Information:

Billing Information

Child/Youth Information

Second Child's Information:

Third Child's Information

Fourth Child's Information:

Medical Information:

Release & Fine Print: