Membership Application 2020-2021
Please complete in its entirety.
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Email *
Club Member Full Name *
Date of Birth *
Ethnicity *
Tribal Affiliation *
Address with city, state and zip code *
Phone Number *
School Child Attends & Grade *
Medical Information - (Doctors name & phone) *
Permission for treatment by doctor/hospital *
Does your family have health and/or accident insurance? *
Does your child have serious health problems? *
Medications *
Household - this information is collected for grant writing purposes only. Member lives with: *
Annual Household Income *
Number in Household *
Is there a member of the household 65+? *
Current single parent? *
Is mother or father incarcerated? *
Is mother or father serving in the military? *
Contact/Pickup Information - Name and Phone Number(s), Relationship *
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