Please Note: One form must be filled out for EACH childBranch*BlantonBurlesonCarrCedar CrestCedar Springs Boys & Girls ClubDadeDouglassDunbarEast Dallas Boys & Girls ClubErvinGrand Prairie Boys & Girls ClubIDEAJohnsonKIPP DestinyKIPP Pleasant GroveLeeLincoln High SchoolLipscombMadison High SchoolMaple LawnMesquite Boys & Girls ClubMLKNavarro County Boys & Girls ClubOak Cliff Boys & Girls ClubPeaseRhoadsRichardson Boys & Girls ClubRoseland Boys & Girls ClubRuskTitcheTruettUplift Wisdom Boys & Girls ClubWest Dallas Boys & Girls ClubWilmer-HutchinsZumwaltNew or Returning Member*NewReturningGender*Please select the gender of the child you are filling out this application on behalf of. Female Male Race*Check all that apply Caucasian African American Hispanic Asian Mixed Other Name*Please enter the name of the student First Last Address*Please enter the primary contact information of the child Street Address Address Line 2 City ZIP Code Phone*Email Birthday* Date Format: MM slash DD slash YYYY School InformationCurrent School*Current Grade*School Address Street Address City ZIP Code School DistrictStudent IDSwimming AbilityHome InformationDo you live with your:* Mother Father Foster Parents Both Parents Stepmother Stepfather Grandparent Other If 'Other", please specifyIs parent or guardian an active member of the military?*YesNoMother's Name First Last Employed?YesNoMother's Work/Cell PhoneFather's Name First Last Employed?YesNoFather's Work/Cell PhoneLegal Guardian's Name First Last Employed?YesNoLegal Guardian's Work/Cell PhoneRelationship to Member*Email Medical InformationPhysician's Name Physician's Address Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact*Relative or Friend, not Parent'/Guardian Relationship to MemberPhone*Address of Emergency Contact Street Address City ZIP Code Does this applicant have any health problems?*Does this applicant have any allergies?*This heath condition restricts applicant from the following activities*N/A if not applicableQuestionnaireReason for Joining Tutoring Homework Help Sports It's a safe place to have fun How did you hear about the Boys & Girls Club of Greater Dallas? Flyer PTA Media Phone Book School Personnel Church Community Block Party Friends Word of Mouth Other Please SpecifyBoys & Girls Club Permission and AcknowledgementsYour child has applied for a membership at the Boys & Girls Clubs of Greater Dallas (“Club”). To help us better serve you and your child, please do the following: 1) Read this form in its entirety and explain it to your child. 2) Supply the information requested. 3) Sign this form and return it to the Club facility your child will be attending. I hereby grant permission for applicant to participate in program activities at the Club. I understand that some of these activities involve sports and field trips, and may take place away from the Club facility. Each time there is a scheduled trip off facility property, I must fill out a Field Trip Permission Form for each instance, water or otherwise. I understand that activities will be supervised by the Club’s staff, but supervision cannot guarantee my child’s safety while he/she participates in these activities. I further understand that some of these activities are potentially dangerous and that the Club cannot, and does not, provide any assurance that my child will not be injured while participating in any activities. In signing this, I am fully aware that the Boys & Girls Clubs of Greater Dallas program is NOT a licensed child care facility and is NOT regulated by the state. I also grant permission for my child to walk to the Club from school alone or with a sibling under the age of 18. By signing this form, I consent to and authorize the use and reproduction by, or as authorized by, the Club, of any and all photographs, videotape, or social media outlets which the Club may take of my child, for any legal purpose whatsoever without any compensation to me or my child. All negatives and positives, together with all prints involving such photographs and any videotape, shall constitute the sole and exclusive property of the club. Also, some information, demographic and otherwise, may be shared with representatives of Boys & Girls Clubs of Greater Dallas and with Boys & Girls Clubs of America. In executing this form I hereby release the Club, its members, employees, and staff, from any and all claims and causes of action, whether in law or in equity, which may at any time exist as a result of my child’s membership in the Club and his/her participation in Club activities. By signing here I affirm that my child’s shot records are kept on file at his/her school located on the front of this form. In executing this form I also agree in the event of emergency illness or accident that a licensed medical doctor shall be authorized to administer medical or surgical treatment deemed necessary for the health or well being of my child. I understand that I will be financially responsible for such care given to my child, and that all reasonable efforts will be made to contact the doctor whose name appears on application before contacting another doctor to treat my child. Boys & Girls Clubs of Greater Dallas reserves the right to deny entry if any member exhibits signs of contagious disease. Parents are responsible for informing club authorized personnel about health problem and/or concerns. I have read and agree with Boys & Girls Club Permission and Acknowledgements* Yes Parent/Guardian Signature*Pick Up Information How will applicant get to the Club? BGCD Bus/Van School Bus Walk Parent Drop Off Other if Other, ExplainWHEN LEAVING THE CLUB, MEMBERS MUST SIGN OUT Members below the age of 14 may only be released to the individuals designated below. If staff do not recognize those picking up members, they my ask for a photo ID (driver's license) or have a photo kept on file. This child to only be released to the following individuals:Name PhoneIdentification (Driver's License #)Name PhoneIdentification (Driver's License #)Name PhoneIdentification (Driver's License #)As the parent or legal guardian, I agree that I must attend a mandatory parent orientation or request a handbook outlining membership expectations and parental obligations.* I agree Parent /Guardian Signature*Applicant/Member Signature*Date Date Format: MM slash DD slash YYYY In accordance with Federal Law, this organization does not discriminate on the basis of age, race, color, gender, disability or national origin.Parent Consent and Release of Liability I do hereby give the staff of Boys & Girls Clubs of Greater Dallas (BGCD) my full permission to request my child’s most current TAKS Scores/TAKS Growth Profile and Six Weeks Report Cards. This is with the understanding that this data will be used by BGCD to establish an action plan to support the academic needs of my child and to measure his/her progress over the course of the school year. BGCD offers an after-school program, Project Learn, in which my child is actively engaged. Through this program, my child participates in high yield learning activities and tutoring, when needed. While all members engage in educational activities, they also participate in the homework assistance program called Power Hour. It is understood that the representatives of Boys & Girls Clubs of Greater Dallas and representatives of Boys & Girls Clubs of America may use this data to further measure the academic gains of its members as a whole. IA am fully aware that I will not receive monetary compensation for my child’s participation in the BGCD programs. Additionally, in no event is BGCD obligated to provide any programs and is not guaranteeing any results from its programs. I further release and relieve Boys & Girls Clubs of Greater Dallas and its Board of Directors, agents, employees and other representatives from any liabilities, known or unknown, arising out of the use of this data. I certify that I have read this Parent Consent and Release of Liability and fully understand its terms and conditions. I understand that the opportunity to participate in the After-School program, Project Learn, is given by Boys & Girls Clubs of Greater Dallas contingent upon my execution of this Parent Consent and Release of Liability. I have full legal capacity to sign this Consent and Release for my child.*I do give permission to release my child's TAKS scores/TAKS growth profiles and/or six week's report cardsI DO NOT give permission to release my child's TAKS scores/TAKS growth profiles and/or six weeks report cardsParent Consent Signature*Statistical InformationThe following information is for statistical purposes only. Please answer all questions completely. Confidentiality: Any confidential information requested is for our records and for the funding our organization receives. The answers you provide will be kept completely confidential. Your cooperation is both appreciated and necessary.Applicant/Member AgeMember Race Caucasian African American Hispanic Asian Mixed Other If Other, explain:Family Income* Under $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50,000 $50,000 and above Family SizeIndicate number of individuals living under one roofLives With:* Single Parent Both Parents Grandparents Foster Parents Other (Aunt, Uncle, etc) Do you receive:* Free/Reduced Lunch Medicaid/CHIP Amerigroup TANF Food Stamps Social Security Income Social Security Disability N/A Please check all that applyWhat is the highest level of education within this household* High School Associate Degree Bachelor's Degree Graduate of Professional Degree Some College Other Prefer Not to Answer This information will remain confidentialMembership FeePay NowPay at the ClubPay now online, or pay upon arrival at the club. Note: We only accept money orders or payment online. Make all money orders payable to individual club, ie East Dallas Boys and Girls Club If you choose to pay now you will be redirected to a payment page, your information will be saved and submitted.Payment InformationMembership Fee* Price: $20.00 Total $0.00 Credit Card American ExpressDiscoverMasterCardVisa Card Number Month010203040506070809101112 Year20202021202220232024202520262027202820292030203120322033203420352036203720382039 Expiration Date Security Code Cardholder Name NameThis field is for validation purposes and should be left unchanged.