Does your family have health and/or accident insurance? Yes No
If your child(ren) does not have health insurance may we contact you? Yes No
Are there any serious health problems that the staff should be aware of? Yes No
If Yes than please explain: ______________________________________________________________
I give my permission for my child to speak to a licensed mental health professional if there is a special need. Yes No
MEMBER:
· I promise to respect myself, respect others and respect the Boys & Girls Club.
Member Signature: __________________________________________ Date: ________________________
PARENT/GUARDIAN:
· I hereby give my permission to my child to become a member of The Boys & Girls Clubs of Central Wyoming.
· I understand that the Boys & Girls Clubs of Central Wyoming has an open door policy and that the Club is not responsible for the time or manner in which my child may arrive or leave the Club.
· I understand that in case of an emergency, a reasonable effort will be made to contact me. In the event that I, or the emergency contact, cannot be reached, I hereby give permission to the Boys & Girls Clubs of Central Wyoming to secure proper treatment (including surgery) for my child.
· In consideration of being allowed to participate in any way in the program, related events and activities, I understand, acknowledge, appreciate and agree that:
1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death.
2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the Boys & Girls Clubs of Central Wyoming, it’s officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and leasors of premises used to conduct the event(“relesees”), and assume full responsibility for my child’s participation.
3. I willingly agree to comply with terms and conditions for participation. If I observe any unusual significant hazard during my child’s presence or participation, I will remove my child from participation and bring such to the attention of the nearest employee immediately.
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless the Boys & Girls Clubs of Central Wyoming, it’s officers, officials, agents and/or employees, other participants, sponsors, advertisers, and, if applicable, owners and leasors of premises used to conduct the event(“relesees”), from any and all claims, demands, losses, and liability arising out of or related to any injury, disability or death my child may suffer, or loss of damage to person or property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law.
· I understand that the Boys and Girls Clubs of Central Wyoming is NOT responsible for personal items brought to the Club, whether lost, stolen, or otherwise missing. We encourage that these items be left at home.
· In addition, I authorize the use and reproduction of any and all photographs and video footage, which may be taken in connection with Club activities, to the Boys & Girls Clubs of Central Wyoming.
Parent/Guardian Signature: _______________________________________ Date: ____________________
Office use only Membership Fee $10.00 October 1 – September 31
Application Date: ____/____/____ Fee Fully Paid: ___ yes___ no Notes:____________________________________________ KT: ___ Renewal: ___ yes___ no Pulled from archive: ___ Card Made: ___ QB: ___
MEMBER INFORMATION – PLEASE PRINT
Circle one: Gender: M F Race: B W H A NAm Multi-Racial
NAME ___________________________________________________________________________________,
FIRST NICKNAME LAST
Would like to be considered for membership in the Boys & Girls Clubs of Central Wyoming
Birthday: _____/_____/_____ Age: _____
School: _______________________________ Grade: ______ Teacher: _____________________________
Please continue on other side