The Black Canyon Boys & Girls Club
Membership Application
$20 dues fee renewed annually in August
Membership # __________ Date ______________Receipt # ____________ NEW / RENEWAL
Child’s Name __________________________________________________________________________
Date of Birth ___/___/___ Age ____ Phone Number ___________________________________________
Home address _____________________________________ City ___________ State___ Zip___________
Mailing address ___________________________________ City ___________ State___ Zip___________
School Name __________________________ Grade ______ Family E-mail address: _________________
How did you hear of the Black Canyon Boys & Girls Club? (circle one) Friend Member Parent Teacher Media Other
Mother’s Name _________________________
Father’s Name ______________________________
Place of Work __________________________
Place of Work ______________________________
Occupation ____________________________
Occupation ________________________________
Work Phone ___________________________
Work Phone _______________________________
MEDICAL ALERT!
A. Does the child have any physical or medical restrictions that would prevent him/her from
participating in Club activities? NO YES
B. Is the child taking any medications we should know about? NO YES
Comments:
________________________________________________________________________
________________________________________________________________________
EMERGENCY CONTACT!
Emergency Contact of person not in the same household: Phone #: ____________________
Name_____________________________ Relationship to child ________________________
WAIVER OF LIABILITY AND DISCLAIMER: In consideration of my son’s/daughter’s membership and participation in the
activities and special programs or events of the Boys & Girls Club, I, as parent or guardian of named minor, my heirs, executors,
administrators and assigns, waive, release and discharge any and all rights and claims or damages against the Black Canyon Boys
& Girls Club and/or its sponsors for all claims arising or resulting from traveling, participating and/ or being involved in its
program or activities. I attest and verify that I have full knowledge of the risks involved in said participation, and that I will, on
behalf of said member, assume and pay and medical or emergency expenses in the event of accident, illness or other incapacity
regardless of whether I have authorized such expenses, and that my son/ daughter is physically fit and sufficiently trained to
participate in the programs or activities of the Boys & Girls Club.
The Boys & Girls Club has an “open door policy” –Members may come and go as they please!
Signature of Parent or Guardian
Printed name of Parent or Guardian
Date
One Parent/Guardian Signature is required for this page
The Boys & Girls Clubs of America request the following information.
Please understand that this information is optional and confidential.
Thank you for your cooperation.
Does your child qualify for the free and reduced lunch program? _____ Yes _____ No
Number of people in household: _____
Parent’s marital status: _____ Married _____ Separated _____ Single
Child lives with: _____ Mother _____ Father _____ Both _____ Aunt/Uncle _____ Foster parents
_____ Grandparents _____ Guardian_____ Other
Race of child: _____ Caucasian _____ African American _____Latino/Hispanic _____ Asian
______ Native American _____ Multi _____ Other
Sex of child: _____ Male _____ Female
Annual income: _____ Less than $9,999 _____ $10,000-14,999 _____ $15,000-19,000
_____ $20,000-24,999 _____ $25,000-29,999 _____ $30,000-34,999
_____ $35,000-39,999 _____ $40,000-44,999 _____ $45,000-49,999
_____ $50,000-54,999 _____ $55,000-59,999 _____ $60,000 and above
PHOTO RELEASE
I hereby grant the Black Canyon Boys & Girls Club, its subsidiaries, affiliates, licensees, successors and
assignees, the right to use my child’s name and likeness in a photograph, filmed production or
advertisement for the Black Canyon Boys & Girls Club. This grant shall extend to any and all phases of
the utilization of the reproduction including publicity, promotion, advertising and marketing.
I hereby represent and certify that I have read the foregoing and fully understand the meaning and effect
thereof and, intending to be legally bound, I set my hand hereunto this day
______________________________ of 20____.
Month
day
_________________________________________________________
Signature of Parent or Guardian
PARTICIPANT EVALUATION
As a participant in the Black Canyon Boys & Girls Club, I agree to be in a study to answer some
questions about my activities, feelings and opinions of the Black Canyon Boys & Girls Club and how my
participation has helped or not helped me. I understand my answers are private and I will not get a grade
for my answers. I can decide to not be in this evaluation at any time without being in trouble.
__________________________________
Member Signature
__________________________________
Parent Signature
RELEASE OF GRADES
I authorize the Black Canyon Boys & Girls Club to review and track my son’s/daughter’s school grades for
the purpose of rewards or incentives.
____________________________________
Parent Signature
CODE OF CONDUCT
I have read and understand the Code of Conduct for the Black Canyon Boys & Girls Club. Please sign
below and remove the Code of Conduct for your records.
____________________________________
__________________________________
Member Signature
Parent Signature
Two Member Signatures and four Parent/Guardian Signatures are required on this page