Club Member Application Form

Youth Information

Youth Full Name (First, Middle, Last)*

New or returning member?*
New MemberReturning Member

Date of Birth (MM/DD/YYYY)*

Gender*
MaleFemaleOther

Ethnicity (please check all that apply)*
CaucasianAfrican AmericanAsianPacific Islander/Native HawaiianHispanic/LatinxNative AmericanOther

Mailing Address (Street)*

City*

State*

Zip Code*

Household Information

Household type*
Both ParentsSingle MotherSingle FatherFoster CareAlternate CustodyGroup HomeHomeless

Primary family size (Number of children, number of adults)*

Does a family member in the household currently or previously serve in the military?*
Active DutyReserveGuardVeteranN/A

Assistance/Income Information

Assistance programs*
Daycare VoucherSNAP/Food stampsGeneral AssistancePublic HousingTANFSSISSDIWICN/A

Lunch Cost*
FreeReducedPaid in Full

Family Income*
Less than $16,250$16,251 - $20,500$20,501 - $24,600$24,601 - $33,000$33,01 - $45,000$45,001 - $70,000$70,001 - $100,000$100,000+Choose not to answer

Academic Information

School for 2020-2021*

Grade (2020-2021)*
1st2nd3rd4th5th

Is your child on an Individual Education Plan or a 504 Plan?*
YesNo

Is your child enrolled in a specialized program? If yes, please list, if no, please enter "N/A".*

Does your child require special accommodations at school?*

The Club will review our ability to make accommodations based on our capacity, facility, and professionals. Parents and/or guardians may be asked to provide accommodations for youth, depending on their needs, if the Club is unable to fulfill needed accommodations. Parents may be asked to meet with supervisors prior to membership acceptance to create a detailed plan for accommodations of youth requesting membership.

Attendance

Which days of the week will your child be attending the Club?*
MondayTuesdayWednesdayThursdayFriday

Medical Information

Does your child have asthma? If yes, and if your child uses an inhaler, please list "inhaler" in the medication section.
YesNo

Does your child have allergies?
YesNo

Does your child require a milk substitute such as lactose free or soy?
YesNo

If yes, please provide a reason for needing a milk substitute.

If yes, please tell us which milk substitute your child prefers.

Medications

All medications required to be in original container with child's first and last name on it. Please refer to our Medication Policy that is outlined on page 11 of our Parent/Guardian Handbook (linked above).

Medication name, dosage and reason:

Health and Wellness

Does your child receive therapy services?

Does your child have any other physical or mental disabilities/challenges, development delays, emotional or behavioral diagnoses, medical conditions, or other information that we should be aware of to help your child participate in Club programs/environment?

Primary Parent/Guardian Information

Full Name*

Relationship to Club Member*

Physical Address*

City*

State*

Zip Code*

Cell phone number*

Home phone number*

Work phone number*

Place of employment*

Occupation*

Primary email address*

Secondary Parent/Guardian Information (Optional)

Full Name

Relationship to Club Member

Physical Address

City

State

Zip Code

Cell phone number

Home phone number

Work phone number

Place of employment

Occupation

Primary email address

Emergency Contacts

Contact 1*
Full Name

Primary Phone Number

Contact 2*
Full Name

Primary Phone Number

Contact 3 (Optional)
Full Name

Primary Phone Number

Contact 4 (Optional)
Full Name

Primary Phone Number

Transportation Information

Please list the first and last name of every person who is allowed to pick up your child from the Club.

Please list anyone who is NOT allowed to pick your child up from the Club.

Bonafide Reason for Needing Care

Bonafide is defined as a work, school, or medical conflict that causes no adequate supervision in your household to be available for your child(ren). Additional documentation may be required.
I attest that my family has a bonafide reason for needing care.