members

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Membership Application (1)

"*" indicates required fields

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 *

First Middle Last

Address *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Age *

Please enter a number from 6 to 20.

Birth Date *

Home Phone

School Attending *

Teacher's Name

Grade *

The grade they are attending during 2022-2023 school year

Please enter a number from 1 to 12.

First Guardian's Name *

First Last

First Guardian's Relationship *

First Guardian's Phone

First Guardian's Email

Second Guardian's Name *

First Last

Second Guardian's Relationship *

Second Guardian's Phone

Second Guardian's Email

Desired Club Location *

South Side — 435 VanRaalte Ave.

Holland Heights — 856 E. 12th St.

North Side — 583 Riley St.

Saugatuck/Douglas — 261 West Randolph St.

Member Status *

New Member

Renewing Member

Gender *

Race/Ethnic Background *

African American/Black

Asian

Caucasian

Hispanic

Native American

Two or more races

Other

Who Does The Child Live With? *

Both parents

Mom only

Dad Only

One parent/ Step-parent

Grandparent(s)

Guardian(s)

Other

Free or Reduced Lunch *

Yes

No

Annual Hosehold Income *

$0 – 4,999

$5,000 – 9,999

$10,000 –24,999

$25,000 – 49,000

$50,000 – over

Emergency Contacts

Must be filled out

Name *

First Last

Phone *

Relationship *

Name *

First Last

Phone *

Relationship *

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 *

Any known allergies *

Behavioral Needs *

Medications *

Member Pledge Principles

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 *

Type Name

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.

Parent/Guardian's Signature *

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. *

Yes

No

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

Yes

No

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

Yes

No

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

Yes

No

Is your child/teen allowed to use the computers at the Club? *

Yes

No

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

Yes

No

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.

Parent/Guardian's Signature *

Type Name

Date *

Youth Services

Our Youth Services Coordinator is available for individual counseling sessions. If you would be interested in your child receiving counseling/therapy services, please check which unit your child attends and day preference (if applicable):

Van Raalte Unit — Monday

Van Raalte Unit — Friday

Riley Unit — Tuesday

Riley Unit — Thursday

Heights Unit — Wednesday

Is your child or teen currently attending counseling sessions?

Yes

No

Parent/Guardian's Signature *

Type Name

Date *

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Full Calendar

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.

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