INCOMPLETE APPLICATIONS WILL NOT BE PROCESSED!

Annual Membership Fee $35.00, Valid from June 1, 2010 through May 31, 2011

Member Information…

Last Name: _______________________________ First Name: _____________________ šGirl šBoy

Telephone: _______________________________ Date of Birth: ____________________ Age: ________________________

Address: _______________________________ Town: _________________________ Zip: _________________________

School: _______________________________ Grade (2010-11 School Year): ___________________________________

Race/Ethnic Background: Caucasian African American Hispanic/Latino Asian Am. Indian Other

E-mail Address: ____________________________________________________________________________

New _________ Renewal_________ Last Year Attended:_______________________________

Pick-Up Authorization: The following individuals, 18 years of age or older, are authorized to pick up my child(ren) from the Clubhouse. I will inform each person listed below that they will be required to present proper identification. Any changes to this list will be made in advance by written notification. I understand that my child(ren) will not be released to those who are not on this list or added in writing.

LAST NAME	FIRST NAME	HOME TELEPHONE NUMBER/CELL NUMBER	WORK TELEPHONE NUMBER	RELATIONSHIP TO CAMPER

My child has my permission to walk or ride on his/her bike home from the Club (Grades 6 & up only): šYes šNo

My child must remain on site to be picked up : šYes šNo

Health Information: handicaps, allergies (including food allergies), medication use, etc.

None Yes, please specify: ______________________________________________________

______________________________________________________

Doctor’s Name:__________________________ Phone Number:_________________________________________

About your family…

Father’s Name: ___________________ Business Phone: ____________________Cell Phone: ____________________

Mother’s Name: ___________________ Business Phone: ____________________Cell Phone: ____________________

Guardian’s Name: __________________ Business Phone: ____________________Cell Phone: ____________________

We would like to learn of any specials skills or talents you might possess and be willing to share with the Club.

Please List: _______________________________________________________________________________Thank You!

Total Household Income (Gross) and Information:

IT IS MANDATORY THAT THIS SECTION OF THE APPLICATION BE COMPLETED, AS IT IS A REQUIREMENT OF OUR FUNDING SOURCES. This information is kept in strict confidence and will have no effect on your cost for the program. Please check (P) one:

_____$0-$57,000 _____$57,001-$65,200 _____$65,201-$73,300 _____$73,301-$81,400 _____$81,401-$88,000

_____$88,001-$94,500 _____$94,501-$101,000 _____$101,001-$107,500 _____$107,501-over

Are you a single-parent family? ____Yes ____No

Number of children in family? ______________

Total number of people in household? ______________

In an emergency, please notify (other than parents):

Name: __________________________________Relationship: _______________ Telephone: _______________________________

Physician: _______________________________Physician’s Telephone: ________________________________________________

Parent/Guardian consent/signature required:

Please Initial:

I give permission to the Boys & Girls Club of Oyster Bay-East Norwich to seek emergency medical treatment for my child if deemed necessary_____

I understand that the Boys & Girls Club of Oyster Bay-East Norwich will not be responsible for lost or stolen property______

I give permission to the Boys & Girls Club of Oyster Bay-East Norwich to exchange information regarding my child with the school district listed on this application. The purpose of this is to help both organizations do a better job of helping the student, if deemed necessary____

I give permission to the Boys & Girls Club of Oyster Bay-East Norwich to survey my child about his/her Club experience, behaviors, skills, and attitudes, using Club survey instruments_____

I fully understand and agree to review the rules as outlined on the reverse side of this form and abide by the following Club policies, which are strictly adhered to, without exception: a.) Serious discipline problems may result in a member being suspended and/or withdrawn from the program, without a refund; b.) Under no circumstances will a refund be issued for absences, changes, withdrawals or terminations, and switching and/or transferring of registrations is not permitted; c.) the Boys & Girls Club will not assume responsibility for lost or stolen items; and d.) Photographs of my child may be used for public relations purposes. I hereby give my approval for my child to attend the Boys & Girls Club with full knowledge and understanding of the above-outlined policies.

Parent’s/Guardian’s Signature: ______________________________________ Date: ________________________

Boys & Girls Club

General Policies

As a member of the Boys & Girls Club, I agree to the following:

1. Members must check in and out at the front desk with their membership card and membership number.

2. Members and their families are to be respectful and cooperate with all staff and members. Members must listen to staff and respect and obey staff decisions and seek help from them if needed.

3. The Club will not tolerate any bullying, fighting, or violence in any form.

4. Members must take good care of the facility and its equipment. Any member not doing so, may be suspended from using said equipment.

5. Members are expected to use appropriate language at the Club. Inappropriate language, which includes the use of profanity, obscenity, and/or abusive language, will not be tolerated. They should always resolve conflicts peacefully and with words.

6. Members and their families are expected to exhibit good sportsmanship during all Club activities and programs.

7. Members must follow all local and state laws pertaining to drugs, alcohol, and tobacco. Our Club and the surrounding grounds is a drug and tobacco free environment.

8. Members are strongly encouraged to keep electronic devices (Ipods, Nintendo DS, cell phones, etc.) at home. The Club is not responsible for any lost or stolen property.

9. All members are expected to leave the Boys & Girls Club upon closing for that day. Anyone who is not picked up on time is subject to a late fee.

10. Members will be expected to respect the property of others.

I will treat others as I want to be treated, and therefore, will not exhibit any behaviors that would be harmful or hurtful to myself or others. I understand that any violation of the above rules may result in suspension of membership privileges.

______________________________________ ___________________________________

Club Member Parent/Guardian