Application for Membership

     Child's Name:   Birthdate:    Age:    Gender: M F     Phone  

Address:      City        State  AL AK AZ AR CA CO CT DE FL DC GA HI ID IL IN IA KS KY LA ME MH MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY       Zip Code  

School:       Grade:      Number of Siblings:    Hobby:

Guardians Names:     Relationship to child: Father  Mother  Other

Email Address:

         Address if Different than above:   Home phone #:

Employed by:     Phone #:     Medical Insurance:

Employed by:     Phone #:     Additional Insurance:

Does your child take medication regularly? Yes  No        If yes, Explain:

Family Doctor:    Phone #:     Hospital Preference:

Emergency Contact:    Phone #:   Relationship to child:

Use the following space to briefly describe your child's physical, mental, and emotional health. In addition, please let us know if your child has any special needs or concerns while participating in our program:

The following information is for statistical purposes only. We appreciate your cooperation.

Ethnicity:        African-American      Asian      Caucasian     Hispanic     Native-American    
                           Pacific Islander            Multi-Ethnic        Other:

Guardian Marital Status:         Married         Divorce/Single Parent     Widow/Single Parent
                                                                                   Never Married/Single Parent

               Head of Household Gender: M F      Number of people living in household: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 More

Total Gross Household Income:  Under 12,000 12,000 - 13.999 14,000 - 16,499 16,500 - 17,999 18,000 - 19,999 20,000 - 23,499 23,500 - 25,999 26,000 - 29,999 30,000 - 37,499 37,500 - 43,999 44,000 - 49,999 50,000 - Up

Once we have received the above application, you will be required to sign a waiver at our
office that reads:

I recognize there is an element of risk in anything outside of the home setting, including the Boys & Girls Clubs. My child may be exposed to physical hazards, emotional demands, communicable diseases, weather conditions, and/or other unanticipated events. I understand that my child is not in a daycare center and that he/she has the option to leave from and return to the club as he/she wishes in accordance with the club's open door policy.

I authorize my child to participate in all the programs and activities of the Boys & Girls Clubs of Elko. Furthermore, my child has permission to participate in any and all field trips away from the club.

On behalf of my child, I assume all risk of my child's participation in these programs and activities. I hereby release and agree to hold harmless the Boys & Girls Clubs of Elko, it's employees, agents, officers, board of directors, and all volunteers from any and all liability, loss or damage actions, claims and demands which I now have or which may hereafter arise from my child's participation in the routine activities of the Boys & Girls Clubs. This release is intended to be binding upon my heirs, executors, and/or personal representatives.

I hereby certify that my child is in normal health and, to my knowledge, is capable of participating safely in any and all programs of the Boys & Girls Clubs of Elko. Should any injury occur during the participation of said programs and activities, I authorize the Boys & Girls Clubs of Elko to arrange for or provide emergency medical treatment and to arrange for or provide transportation to the nearest medical facility. I understand that the Boys & Girls Club does not carry medical insurance for members.

I authorize the Boys & Girls Clubs of Elko to use photos, videotape footage, and/or sound recordings of my child for the purpose of, but not limited to, television, newspapers, billboards, bus covers, public development videos, printed materials, and/or news coverage. Moreover, I hereby waive claim to any rights residuals or fees in connection with the use of said photos, videotape footage, and/or sound recordings.