Membership Application (1)

"*" indicates required fields

Desired Club Location * Required

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
Address * Required
Please enter a number from 6 to 20.
MM slash DD slash YYYY
Please enter a number from 1 to 12.
The grade they are attending during 2023-2024 school year
First Guardian's Name * Required
Second Guardian's Name * Required

Emergency Contacts

Must be filled out
Name * Required
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
* 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
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
I give permission for my son’s/daughter's image to be used in Club social media pages/videos/marketing. * Required
Does your child have permission to take public transportation home (MAX or InterUrban) * Required
Does your child or teen have an IEP at school? * Required

Consent For Club/School Communications

* Required
Type Name
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
MM slash DD slash YYYY
I have paid for my child's membership * Required
I give permission for Club Staff to text/ call me for schedule updates. * Required

If your child is in the 1st-5th grade or a first time member who is 6th-12th grade, a parent or guardian will be required to attend an orientation before the child or teen can access club programming.

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.