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Roosevelt Clubhouse. Cabazon. Anna Hause. Central. Brookside. Coombs. 2010/2011 MEMBERSHIP APPLICATION. 3 Rings Ranch. Hemmerling. Sundance. Hoffer. Tournament Hills. Nicolet. MEMBER INFORMATION:. Nick Name:______________________. Last Name:__________________________.

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slide1

Roosevelt Clubhouse

Cabazon

Anna Hause

Central

Brookside

Coombs

2010/2011 MEMBERSHIP APPLICATION

3 Rings Ranch

Hemmerling

Sundance

Hoffer

Tournament Hills

Nicolet

MEMBER INFORMATION:

Nick Name:______________________

Last Name:__________________________

First Name:______________________

African American Asian Caucasian Hispanic Native American Multi-Racial Other:____________________________

Please

Circle

Gender:

M F

Date of Birth:_________________

Ethnicity:

Age:______

Address:__________________________________________________________ , ____________________ , CA ____________

Zip

City

Telephone:_______________________________________________

Email:_____________________________________________________________________________

TO RECEIVE CLUB NEWS

Teacher:_____________________

School:_____________________________

Grade:_____

Number of people in household:______

$0-18,000 $18,001-24,000 $24,001-26,000 $26001-28,000 $28,001-41,500 over $41,500

Please

Circle

Does child receive Free Lunch at school?

Household Income:

Y N

Mother Father Both Other:__________________________

Child lives with:

Please Circle

Circle All Programs That Apply: TANF SSDI SSI GENERAL ASSISTANCE FOOD STAMPS OTHER:_____________________________

PARENT / GUARDIAN 2:

PARENT / GUARDIAN 1:

Name:_______________________________________

Name:_______________________________________

Relationship:_______________ Employer:___________________

Relationship:______________ Employer:____________________

Telephone:_________________________

Telephone:_________________________

Home Cell Work

Home Cell Work

Please

Circle

Please

Circle

Telephone:_________________________

Telephone:_________________________

Home Cell Work

Home Cell Work

Home Cell Work

Telephone:_________________________

Telephone:_________________________

Home Cell Work

ADDITIONAL NAMES AUTHORIZED TO PICK-UP CHILD:

EMERGENCY CONTACTS:

Name:__________________________________

Relationship:_____________________________

Name:_______________________________

Home Cell Work

Telephone:______________________________

Relationship:__________________________

Please

Circle

Telephone:______________________________

Home Cell Work

Name:_______________________________

Name:__________________________________

Relationship:__________________________

Relationship:_____________________________

Name:_______________________________

Telephone:______________________________

Home Cell Work

Please

Circle

Telephone:______________________________

Relationship:__________________________

Home Cell Work

MEDICAL:

Medication:

Y N

List Medication:_____________________________________

Please

Circle

Food Allergy:

Y N

List Food Allergy:_____________________________________

OFFICE USE ONLY:

Date:_______________________

Staff Int:_______________________

Contact us at:

(951) 922-3259 fax: (951) 922-2141

www.bgcsgpass.comadmin@bgcsgpass.com

PO Box 655, Beaumont, CA 92223

Card #:_______________________

slide2

MEMBERSHIP APPLICATION PAGE 2 OF 2

PARENT / GUARDIAN CONSENT

DISEASES

HEALTH HISTORY

ALLERGIES

Frequent Ear Infections

Ivy Poisoning

Chicken Pox

Bleeding/Clotting Disorders

Hay Fever

Measles

Heart Defect/Disease

Insect Stings

German measles

Convulsions

Penicillin

Mumps

Diabetes

Other Drugs

Asthma

MEDICAL RELEASE

This health history is correct so far as I know and the person herein described has permission to engage in all prescribed Club activities except as noted by the examining physician and me. I hereby give permission to the physician selected to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named on this application. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

HOLD HARMLESS CLAUSE

I further agree that the Boys & Girls Clubs of the San Gorgonio Pass, it’s Board of Directors, officers, staff and volunteers are hereby relieved of any and all liability, including but not limited to medical treatment, emergency transport or on-site assistance, in the event of accident or injury to the said minor.

OPEN DOOR POLICY – DOES NOT APPLY TO SCHOOL SITES WHEN SCHOOL IS IN SESSION

I understand the Boys & Girls Clubs of the San Gorgonio Pass has an “Open Door” policy that allows Club members to enter and leave the Clubhouse facilities as they choose. I understand that other adjacent areas outside the Clubhouse may not be supervised by the Boys & Girls Club staff, and because of the “Open Door” policy, my role as a parent determines where my child can play. Therefore, I agree that the Boys & Girls Club is not responsible for my child if they leave the Clubhouse premises. Also, I understand the Boys & Girls Clubs of the San Gorgonio Pass is not a licensed day care provider by its’ own choice.

PUBLICIITY RELEASE

I hereby consent to authorize the reproduction, publication and use the Boys & Girls Clubs of the San Gorgonio Pass and Boys & Girls Clubs of America, and their successors and assigns, for advertising, commercial, or any other purposes of any photograph picture or likeness of my child.

CONSENT

I have read and understand the above and hereby give my permission for my child to become a member of the Boys & Girls Clubs and to have my permission to participate in all the activities/programs offered by the Boys & Girls Clubs. I understand that my child must have good behavior and the Boys & Girls Club is a private organization and membership is a privilege and my be revoked at anytime. Additionally, I understand that the Boys & Girls Clubs is not responsible for the time or manner in which my child may arrive at or leave the Clubhouse, and that the Boys & Girls Club and its property are not responsible for personal injury or loss of property.

Parent / Guardian signature: ____________________________________ Date: ___________________

Contact us at:

(951) 922-3259 fax: (951) 922-2141

www.bgcsgpass.comadmin@bgcsgpass.com

PO Box 655, Beaumont, CA 92223