2017-18 Membership Application

Becoming a Boys & Girls Clubs of Alameda member is easy. The Club offers many fun-filled, value-based programs that include technology, arts and crafts, games, team sports, homework help, and so much more. Visit our club for a tour and to pick up a membership application.

Membership are for Children and Youths ages 6 years old through 18 years old

Type:

Membership Fee Scholarship must be approved by Alameda Boys & Girls Club

First Name Middle Name Last Name
Age Birth Date Gender
Address
City State Zip
Home or Cell Telephone Number Parent/Guardian e-mail address
Emergency contact Emergency Telephone Number
Authorized Pick Up Telephone
Authorized Pick Up Telephone

Race/Nationality (for reporting purposes only)

Do you identify yourself as Hispanic or Latin? Check One  Select Yes No
Ethnicity

School Infomration

School Grade

Family Information

Mother's First Name Last name
Mother's Work Telephone Area Code Phone Number
Father's First Name Last Name
Guardian First Name Last Name (if different from mother or father)
Relationship to guardian
Guardian Work Telephone Area Code Phone Number
Parent/Guardian e-mail address
Emergency contact
Telephone
Head of Household
Total Number of Household Members (Include all adults and children)

It is important for future funding that we track average household income for our membership. All information will be confidential and will not be supplied
to any other person(s) and/or agencies.

Family Gross Annual Income (for reporting purposes only) Please Highlight One:

Family Gross Annual Income

Medical Information

Doctor’s name
Telephone
Does your family have health and/or accident insurance?  Yes No
Insurance Provider Group Number
Does applicant have any disabilities?  Yes No
If yes, please specify

Please indicate any medical problems and/or allergies

Please indicate any medication presently taking

Parental/Guardian Release Form

Safe Guard Policy:

I, the parent/guardian of the minor child listed on this application, understand and agree to adhere to the Club’s Safe Guard Policy as it pertains to my child, who is between the age of 6 & 11. I also understand that the reason for this policy is to ensure a safer environment for my child while at the ABGC. Cneck box if you agree  Agree

Surveys and Questionnaires:

I, the parent/guardian of the minor child listed on this application, give permission for the Boys & Girls Club of Alameda to survey my child about his or hers Club experience and behaviors, skills and attitudes using Boys & Girls Club Of America’s Youth Development Outcome Measurement Tool Kit surveys or other survey instruments. Check box if you agree  Agree

Technology:

As a member of the Boys & Girls Club of Alameda, your child will have access to the Internet. While precautions are being taken, it is possible that s/he may access inappropriate sites. The Boys & Girls Club will have rules and consequences at the Club for such behavior; however we will not be responsible for the consequences of such access.
Check box if you agree  Agree

Surveys and Questionnaires:

I, the parent/guardian of the minor child listed on this application, give permission for the Boys & Girls Club of Alameda to survey my child about his or hers Club experience and behaviors, skills and attitudes using Boys & Girls Club Of America’s Youth Development Outcome Measurement Tool Kit surveys or other survey instruments.
 Yes No

Photo and Media:

I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by the Boys & Girls Club of Alameda and its activities.  Yes No

Health Screenings:

The ABGC hosts free Health Screenings throughout the year (Health, Vision, & Dental), for our members. Would you like information regarding upcoming Health Screening events at the Club?  Yes No

I hereby approve my child’s application for membership into the Alameda Boys & Girls Club program. It is understood that if my child is injured while participating in a Club sponsored activity; the Alameda Boys & Girls Club will be held harmless. In case of an emergency, I give my consent for my child to receive medical treatment by a physician or a hospital.  I Agree I Disagree

By checking this box, I acknowledge that I have read the above referenced information and hereby certify that the information submitted on this form is correct and accurate to the best of my knowledge.

Submit