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Epic Membership Form

Epic Application 24-25

"*" indicates required fields

I am signing up for Epic
I am a teen.
If you are an elementary or jr room member please fill out the regular membership form.

Teen Information

An annual parent orientation is required if you have a child in the 1st-5th grade, or a child in the 1st-7th grade who will be a new member for the first time. The parent or guardian will be contacted to set-up an orientation time & date” and “The $5 membership fee covers one membership year (September 1 – August 31) and must be renewed each year
Teen's Name * Required
Address * Required
Please enter a number from 6 to 20.
Select date MM slash DD slash YYYY
Please enter a number from 1 to 12.
The grade they are attending during 2023-2024 school year. If your child is in the 1st grade, you might be asked for verification.
First Guardian's Name * Required
Second Guardian's/ Emergency Contact Name * Required

Medical Information

Epi pens, insulin and inhalers are the only medications allowed on Club property. There is a special medical release form that must be filled out and returned to the Club.

Member Status * Required
Race/Ethnic Background * Required
Who Does The Child Live With? * Required
Free or Reduced Lunch * Required
Annual Hosehold Income * Required

Member Pledge Principles

* Required
Type Name

Policy Agreement & Medical Consent To Treatment

I give permission for my son/daughter to receive medical care in case of an emergency. This might include x-ray, anesthetic, medical and surgical treatment. * Required
Does your child or teen have an IEP at school? * Required
Does your child have an assigned ParaPro for behavioral issues at school? * Required
I give permission for my son’s/daughter's image to be used in Club social media pages/videos/marketing. * Required
I give permission for EPIC staff to text/ email my child. * Required

Consent For Club/School Communications

* Required
Type Name
Select date MM slash DD slash YYYY

Youth Services

At the Boys & Girls Club we have Wellness support staff available to met the additional behavioral and emotional needs or your child. The sessions can occur one on one or in a small group setting. Please check to acknowledge these services might be given. * Required
Type Name
Select date MM slash DD slash YYYY
I give permission for Club Staff to text/ call me for schedule updates. * Required
Does your child have permission to take public transportation home (MAX or InterUrban) * Required
Is your child allowed to walk/bike home (1st—12th grade)? * Required
Do you give your 8th—12th grader permission to leave the Club unattended? * Required
This field is for validation purposes and should be left unchanged.