members

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 1 to 20.

Birth Date *

Home Phone

School Attending *

Teacher's Name

Grade *

The grade they are attending during 2021-2022 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 *

Trailblazers

Holland Heights Club | Grades 5 –7

This program teaches leadership, allowing club members to participate in various service projects around town.

Lead League

South Side Club | Grades 1 –4, 8 –12

This program teaches youth the importance of teamwork and being a respectful and kind team player. It also provides our teens and elementary youth to form mentorship bonds.

To Graduation & Beyond

North Side Club | Grade 12

This program gets members who are in their final year of high school with pre-graduation guidance, helping ensure members have a plan for after high school

Work Related

North Side Club | Grades 5-7

This program is affiliated with the ‘Big Bux’ program, and incentivises a focus on academics.

Cast Club

North Side Club | Grades 4 – 7

This program dives into the world of Podcasts, teaching members all the essential podcast tools, an includes practice fun-filled interviews

Mission Imposterble

South Side Club | Grades 1 – 4

During this program youth play an “Among us” type game with educational tasks that focus on- science, critical thinking, reading, engineering, math, and physical activity.

Power Hour

South Side Club | All Ages

During this program youth of all ages are able to get the homework help they need with staff and volunteers to assist them. The program is funded in part by the Greater Ottawa County United Way in support of their Education initiative to ensure that all our communities youth are progressing from grade level to grade level to graduation!

Superior Threads

Holland Heights Club | Elementary & Middle School

This program teaches members basic sewing skills. Kids will learn to create & repair every day items with sewing.

Soaring to New Heights

Holland Heights & North Side Clubs | Grades 1 – 4

This program explores art’s surealism and self-expression. Members experiment with gouache, spray paint, clip art, and other digital venues

Make Your Mark

South Side Club | Grades 8 – 12

This program gives youth the chance to use their voice and work together to create something special and meaningful to them. Teens work together to design a Tshirt for them and their fellow Club Members and staff to wear.

Curtain Call

South Side Club | Grades 1 – 4

This program teaches youth about acting and works to get them out of their shell through doing silly ice breakers and fun games.

The Big READ

Holland Heights Club | Grades 1 – 4

This program dives into diverse book and book topic analysis. Members will explore books using food music and art.

Sakwamdo Boxing

South Side Club | All Ages

Sakwamdo Boxing has partnered with the Boys & Girls Club to teach boxing skills to youth of all ages.

Write It Out

South Side Club | Grades 1 – 4

This program gives youth the chance to learn the art of journaling to express their thoughts and feelings.

Emoji Ninjas

South Side Club | Grades 1 – 4

This program teaches youth about different emotions they may feel- like happy, angry, hungry, or positive. It teaches youth how to work through negative feelings and live into the positive ones.

Legends of Tefiti

South Side Club | Grades 1 – 4

This program brings youth through the movie “Moana” and teaches them about the characters and the way they all have a purpose and a place in the community to be a leader. Youth also get to work on fun crafts that represent each character during the program.

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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South Side Club & Main Offices
435 VanRaalte Ave Holland, MI 49423
616-392-4102

North Side Club
583 Riley St. Holland, MI 49424
616-786-9011

Holland Heights
856 E 12th St. Holland, MI 49423
616-298-0764

Douglas Elementary
261 W Randolph Street Douglas, MI 49406
616-210-4932

Boys & Girls Clubs of Greater Holland is a 501(c)3 nonprofit, tax-exempt organization as designated by the Internal Revenue Code. Our Federal Tax ID number is 38-2756671.