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Membership Application 2020-2021
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* Indicates required question
Email
*
Your email
Club Member Full Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Ethnicity
*
Native American or Alaskan Native
Caucasion
Hispanic or Latino
African American
Asian
Other
Tribal Affiliation
*
Your answer
Address with city, state and zip code
*
Your answer
Phone Number
*
Your answer
School Child Attends & Grade
*
Your answer
Medical Information - (Doctors name & phone)
*
Your answer
Permission for treatment by doctor/hospital
*
Yes
No
Does your family have health and/or accident insurance?
*
Yes
No
Does your child have serious health problems?
*
Yes
No
If yes, please explain
Medications
*
Your answer
Household - this information is collected for grant writing purposes only. Member lives with:
*
Mom
Step-mom
Dad
Sted-dad
Grandparent(s)
Foster parent(s)
Other
Both parents
Annual Household Income
*
$0 - $20000
$20001 - $40000
$40001 - $65000+
Number in Household
*
Your answer
Is there a member of the household 65+?
*
Yes
No
Current single parent?
*
Yes
No
Is mother or father incarcerated?
*
Yes
No
Is mother or father serving in the military?
*
Yes
No
Contact/Pickup Information - Name and Phone Number(s), Relationship
*
Your answer
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