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 * Required
Address * Required
Please enter a number from 6 to 20.
MM slash DD slash YYYY
The grade they are attending during 2022-2023 school year
Please enter a number from 1 to 12.
First Guardian's Name * Required
Second Guardian's Name * Required
Desired Club Location * Required
Member Status * Required
Race/Ethnic Background * Required
Who Does The Child Live With? * Required
Free or Reduced Lunch * Required
Annual Hosehold Income * 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 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
Is your child/teen allowed to use the computers at the Club? * Required
Does your child have permission to take public transportation home (MAX or InterUrban) * Required

Consent For Club/School Communications

* Required
Type Name
MM slash DD slash YYYY

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):
Is your child or teen currently attending counseling sessions?
Type Name
MM slash DD slash YYYY

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.