members

Membership forms, the $5 fee, and an orientation all must be done before a member can attend the Club.

If you are unable to pay the $5 membership fee scholarships are available. Please reach out to the unit director for scholarship information.

Pay Now

Formulario de membresía en español

Epic Member Only Application

Membership Application 24-25

"*" indicates required fields

Desired Club Location * Required

South Side — 435 VanRaalte Ave.

Holland Heights/ Longfellow — 36 E 24th St

North Side — 583 Riley St.

Saugatuck/Douglas — 261 West Randolph St.

EPIC (Teen Program, please also select Club location)

Child 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

Child's Name * Required

First Last

Address * Required

Street Address City State / Province / Region ZIP / Postal Code

Age * Required

Please enter a number from 6 to 20.

Birth Date * Required

MM slash DD slash YYYY

Tee Shirt Size (please specify childrens or adults) * Required

Home Phone * Required

School Attending * Required

Grade * Required

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.

If your child is a teen (8-12th grade) Please provide their cell-phone number

If your child is a teen are they interested in participating in EPIC, the Club's life readiness program?

Yes

First Guardian's Name * Required

First Last

First Guardian's Relationship * Required

First Guardian's Phone * Required

First Guardian's Email * Required

Second Guardian's Name * Required

First Last

Second Guardian's Relationship * Required

Second Guardian's Phone * Required

Second Guardian's Email * Required

Emergency Contacts

Must be filled out

Name * Required

First Last

Phone * Required

Relationship * Required

Name * Required

First Last

Phone * Required

Relationship * 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.

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 * Required

Race/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

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

* Required

As the parent or guardian of a Club member, I will treat staff and volunteers respectfully. If there are issues that arise, I will work with the staff to create the best plan for my child. If I don't comply, I understand my child(ren) could lose privileges to the club.

Parent/Guardian's Signature * 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

Yes

Does your child have permission to take public transportation home (MAX or InterUrban) * Required

Yes

Is your child allowed to walk/bike home (1st—12th grade)? * Required

Yes

Does your child or teen have an IEP at school? * Required

Yes

Do you give your 8th—12th grader permission to leave the Club unattended? * Required

Yes

Does your child have an assigned ParaPro for behavioral issues at school? * Required

Yes

I give permission for my son’s/daughter's image to be used in Club social media pages/videos/marketing. * Required

Yes

Consent For Club/School Communications

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. * Required

Yes

Parent/Guardian's Signature * Required

Type Name

Date * Required

MM slash DD slash YYYY

Youth Services

At the Boys & Girls Club we have Wellness support staff available to meet the additional behavioral and emotional needs or your child. The sessions can occur one on one or in a small group setting. Please check if your child is allowed to receive these services. * Required

Yes, my child can receive these services.

No, I do not want my child to receive these services.

Parent/Guardian's Signature * Required

Type Name

Date * Required

MM slash DD slash YYYY

Please Pay Before Submitting (https://secure.givelively.org/donate/boys-girls-club-of-greater-holland/membership)

I understand I will need to pay a membership fee of $5. * Required

Yes

I give permission for Club Staff to text/ call me for schedule updates. * Required

Yes

If your child is in the 1st-5th grade (even if they have attended the Club before) or a first time member who is 6th-12th grade,the child along with a parent or guardian will be required to attend an orientation before the child or teen can access club programming.

South Side Orientation Options

Monday's @6:30

Wednesday @6:30

If you are signing your 1-5th grader up or a first-time club member up for the South Side Club please select which orientation works best for you.

Heights Orientation Options

Tuesdays @6-6:30

Thursdays @6-6:30

If you are signing your 1-5th grader up for the Heights extension site please select which orientation works best for you.

Comments

This field is for validation purposes and should be left unchanged.

Gateway Preschool

Investment in early childhood school education is an investment in our future workforce and leaders. Our partnership with the Gateway preschool program and Holland’s Ready for School initiative provides opportunities for our Club families to enroll their children in a high-quality preschool experience.

Apply Today

DONATE