Boys & Girls Clubs of Weld County Member Registration Form
Member Information
First Name
Your answer
Last Name
Your answer
Birth Date
MM
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DD
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Age
Your answer
Gender
Race
What is the primary language spoken at home?
Home Address
Street Address
Your answer
City
Your answer
State
Your answer
Zip Code
Your answer
School Information
Name of School
Your answer
Grade
Your answer
Eligibility for School Lunch Program
Student ID #
Your answer
Special Education Designations:
Walker Authorization
Primary Parent / Guardian
First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
E-mail Address
Your answer
Relationship to Member
Your answer
Place of Employment
Your answer
Other Parent/Guardian
First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
Relationship to Member
Your answer
Place of Employment
Your answer
Authorized person for Pick-Up / Emergency Contact
First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
Relationship to Member
Your answer
2nd Authorized Person for Pick-Up / Emergency Contact
First Name
Your answer
Last Name
Your answer
Phone Number
Your answer
Relationship to Member
Your answer
Household Information
Does this child live in a single parent household?
Household Income
Are you eligible for government assistance (ex: TANF, Food Stamps, Medicaid, etc)?
Medical Information
Are there any physical restrictions that prevent your child from participating in Club activities?
If yes, please explain
Your answer
List any known allergies or dietary restrictions, such as food, bees, plants, etc, and medications that accompany them below:
Allergies:
Your answer
Dietary Restrictions:
Your answer
Medications:
Your answer
By printing my name below, I acknowledge that the information I provided is correct to the best of my ability.
Print Name
Your answer
Today's Date
MM
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DD
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YYYY
Parent / Guardian Agreement
Any confidential information requested is only for our records and for the funding our organization receives.
Liability:

In consideration of my child’s membership and participation in the activities, program, or events of the Boys & Girls Clubs of Weld County (BGCWC), I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge BGCWC and Boys & Girls Clubs of America (BGCA), their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.

Medical Treatment:
I give permission to BGCWC to seek any medical treatment for my minor child that BGCWC deems necessary and appropriate in its sole discretion. I attest and verify that I have full knowledge of the risks involved in said participation, and that I will, on behalf of said member, assume and pay any medical or emergency expenses in the event of accident, illness or other incapacity regardless of whether I have authorized such expenses.

Data Collection:
I give my permission to BGCWC 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, BGCA, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.

Data Sharing:
I understand that BGCWC may share information about the minor child listed on this application with 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 minor child’s school or school district, and other information collected by BGCWC, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

Release of School Information:
I give my permission to BGCWC and local school districts to exchange aggregate information regarding BGCWC members including grades, CSAP scores, school attendance records, and school district assessment results. The purpose of the exchange is to help both organizations do a better job of helping students be successful in school, in the Boys & Girls Club, and in life.

Technology:
As a member of the Boys & Girls Club, your child will have access to the Internet. While precautions are being taken, it is possible he or she may access inappropriate sites. BGCWC will have rules and consequences at the Club for such behavior; however we will not be responsible for the consequences of such access.

Transportation:
I give my permission for my child to participate in activities and programs of BGCWC that necessitate transportation in club vehicles. I understand that often local day trips may be unannounced. Out of town trips will be posted in advance. I understand that all trips will be under the supervision of the Boys & Girls Club staff and that I will not hold the Boys & Girls Clubs of Weld County responsible or liable in case of an accident.

Miscellaneous:
- I understand that the Boys & Girls Club is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. As a drop-in facility, we are not responsible for Club members’ whereabouts outside of the Club.
- I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club and its activities.
- I understand that any child left 30 minutes after the club is closed is by law considered abandoned and must be reported to the authorities, who will then pick up the child.
- I understand that prevention based programming is available for my child at the Boys & Girls Clubs. A trained staff member has my permission to discuss, at a level determined to be age appropriate, the following subject matters: drugs and alcohol, chemical abuse, human anatomy, mental health issues, interpersonal relationships, and values clarification.

By typing my name below, I acknowledge that I understand and agree to all of the information above regarding:
Child's Name:
Your answer
Parent / Guardian's Name:
Your answer
Today's Date
MM
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DD
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YYYY
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