Epic Membership Form Epic Application 24-25 "*" indicates required fields I am signing up for Epic Yes No I am a teen. Yes No If you are an elementary or jr room member please fill out the regular membership form.Teen InformationAn 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 yearTeen's Name * Required First Middle Last Address * Required Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Age * RequiredPlease enter a number from 6 to 20.Birth Date * Required MM slash DD slash YYYY Tee Shirt Size (please specify childrens or adults) * Required Teen Cell Phone * RequiredTeen Email * Required School Attending * Required Grade * RequiredPlease 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 First Last First Guardian's Relationship * Required First Guardian's Phone * RequiredFirst Guardian's Email Second Guardian's/ Emergency Contact Name First Last Second Guardian's/ Emergency Contact Relationship Second Guardian's/ Emergency Contact PhoneSecond Guardian's/ Emergency Contact Email Medical InformationEpi 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.Medical Condition * Required Any known allergies * Required Behavioral Needs * Required Medications * Required Member Status * Required New Member Renewing Member (Has your child ever been a member of the club) Gender * RequiredMaleFemaleOtherPrefer Not to AnswerRace/Ethnic Background * Required African American/Black Asian Caucasian Hispanic Native American Two or more races Other Who Does The Child Live With? * Required Both parents Mom only Dad Only Shared Custody One parent/ Step-parent Grandparent(s) Guardian(s) Other How Many People Live in the Household * Required Free or Reduced Lunch * Required Yes No Annual Hosehold Income * Required $0 – 4,999 $5,000 – 9,999 $10,000 –24,999 $25,000 – 49,000 $50,000 – over Member Pledge Principles * Required I will give my best effort in all Club activities, treat others respectfully and through my positive behavior, promote a sense of fair play, honesty, and good sportsmanship. I will respect the staff, volunteers, others members and myself. I will be respectful of the Club and its surroundings. I understand that the Boys & Girls Clubs of Greater Holland is not responsible for any lost, stolen, or damaged property. I agree to uphold the member Pledge Principles: Member's Signature * Required Type Name Policy Agreement & Medical Consent To TreatmentI 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 Yes No Does your child or teen have an IEP at school? * Required Yes No Does your child have an assigned ParaPro for behavioral issues at school? * Required Yes No I give permission for my son’s/daughter's image to be used in Club social media pages/videos/marketing. * Required Yes No I give permission for EPIC staff to text/ email my child. * Required Yes No Consent For Club/School Communications * Required I give the Boys & Girls Club staff permission to communicate and exchange information with the schools regarding my child’s academic (progress and grade reports), social and emotional behavioral development. Parent/Guardian's Signature Type Name Date MM slash DD slash YYYY Youth ServicesAt 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 I understand Parent/Guardian's Signature Type Name Date MM slash DD slash YYYY I give permission for Club Staff to text/ call me for schedule updates. * Required Yes No CommentsThis field is for validation purposes and should be left unchanged.
