Membership

Child Information

Middle Name

Last Name

T-Shirt Size (shirts may or may not be available) T-Shirt Size (shirts may or may not be available) *SmallMediumLargeXL2X3X

Ethnicity

Birth Date

Age

Gender Gender *MaleFemale

Address

Mailing Address (if different)

City

State State *ArkansasOklahoma

Zip Code

School Information

Current Teacher

Current Grade Current Grade *1st2nd3rd4th5th6th7th8th9th10th11th12th

Food Assistance Program Food Assistance Program *FreeReducedNone

Parent/Guardian Information

Email Address

Employer

Occupation

Home Address

Work Address

Relationship to child

Primary Phone

Other Phone

I give my consent for the Boys & Girls Club of Leflore County to use my child’s photograph for public and promotional purposes. This may be done through the organization’s brochures, video, website, media coverage, and annual campaign materials. I give my consent for the Boys & Girls Club of Leflore County to use my child’s photograph for public and promotional purposes. This may be done through the organization’s brochures, video, website, media coverage, and annual campaign materials. I Agree

I authorize the Boys & Girls Club of Leflore County to take my child on all off campus field trips sponsored by the club. I authorize the Boys & Girls Club of Leflore County to take my child on all off campus field trips sponsored by the club. I Agree

I give consent for my child to participate in all programs* offered by the Boys & Girls Club of LeFlore County. I give consent for my child to participate in all programs* offered by the Boys & Girls Club of LeFlore County. I Agree

Additional Contact/Pickup

New Field

Primary Phone

Secondary Phone

Address

Employer

Is one or more of the child(s) parents or guardian enlisted in or a current service member of the military? Is one or more of the child(s) parents or guardian enlisted in or a current service member of the military? Yes No

Branch?

Medical Information

Doctor Phone

Serious health problems? Serious health problems? Yes No

Explain

Does child take medication? Does child take medication? Yes No

New Field

Does child have any allergies? (ex. food, medication, bees) Does child have any allergies? (ex. food, medication, bees) Yes No

Allergy List

Our goal is to provide our members with access to technology and opportunities to learn in a fun environment. We also aim to ensure our youth are safe in their technology usage and have expectations and guidelines we expect our youth to follow. With ever-changing technology, these change often. Youth are expected to keep screens visible to staff at all times and to use these devices only in the established areas. Cyber-bullying is strictly prohibited and will not be tolerated. At times we will ask that all devices be put away and unused. Members are expected to respect these guidelines. Our goal is to provide our members with access to technology and opportunities to learn in a fun environment. We also aim to ensure our youth are safe in their technology usage and have expectations and guidelines we expect our youth to follow. With ever-changing technology, these change often. Youth are expected to keep screens visible to staff at all times and to use these devices only in the established areas. Cyber-bullying is strictly prohibited and will not be tolerated. At times we will ask that all devices be put away and unused. Members are expected to respect these guidelines. I Agree

I understand that care for injuries that may occur during my child’s active participation in Boys & Girls Club of Leflore County are the responsibility of myself, my family and/or my insurance. I understand that care for injuries that may occur during my child’s active participation in Boys & Girls Club of Leflore County are the responsibility of myself, my family and/or my insurance. I Agree

Discipline issues will be dealt with on an individual basis. Minor discipline issues will result in a warning to the student, if the issues continue we will inform the parent/guardian. A serious disciplinary problem is one in which a youth disrupts the fun and safety of other. This might include but is not limited to a student inflicting physical or emotional harm to another student, abusing staff, or not complying to the behavior expectations. The program has the right to suspend a child if the child is endangering him/herself, other students, or staff members. Discipline issues will be dealt with on an individual basis. Minor discipline issues will result in a warning to the student, if the issues continue we will inform the parent/guardian. A serious disciplinary problem is one in which a youth disrupts the fun and safety of other. This might include but is not limited to a student inflicting physical or emotional harm to another student, abusing staff, or not complying to the behavior expectations. The program has the right to suspend a child if the child is endangering him/herself, other students, or staff members. I Agree

Parent Signature

Date