Lubbock Boys & Girls Club
Membership Application
Circle Club Name:TED PHEAOPTIMISTTALKINGTON

JOHN WILSONSHALLOWATERFirst Name: ___________________________ Middle: _________________ Last: __________________________
Gender: ______M ______F

Ethnicity: ________________________

DOB: ___________________________ AGE: ___________________

Address: __________________________________________City____________________________State_____________Zip_______________
Parent’s/Guardian’s Names: ____________________________________________________________________________________________
Parent’s/Guardian’s Phone: ___________________________ Cell: _____________________ Email: __________________________________

Emergency Contacts:Name/Relationship_________________Phone/Cell#:___________________________Phone/Cell#:____________________________
Name/Relationship_________________Phone/Cell#:___________________________Phone/Cell#:____________________________
Name/Relationship_________________Phone/Cell#:___________________________Phone/Cell#____________________________

School Information:
Current Teacher: ________________________________________________________Do you qualify for Free/Reduced Lunch? _____________
School: _________________________________________________ Grade: ______________________

Medical Information: Doctor Name: __________________________________ Doctor Phone: _________________________
Serious Health Problems: ___Yes ___No

If Yes, explain: _____________________________

Does your family have health and/or accident insurance: ____Yes ____No
Permission for Treatment by Doctor/Hospital: ____Yes ____No

Household:Date of Last Medical Exam: _______________

Preferred Hospital_______________________________________

Medicaid: ____Yes ____No

Medications: ___Yes ___No

If Yes, explain:

NOTE: This information is collected for Grant writing purposes ONLY

Member lives with: ___Mom ___Step Mom ___Dad ___Step Dad ___Grandparent ___Foster parent(s) ___ Other_________________________
Current Head of Household: ________Female________Male_________BothCurrent Single Parent:_________Yes________No

Physical: Eye Color: ____________Hair Color: ______________ Skin Color /Features____________ Height: _________ Weight: _________
Member of other groups? _____Boy Scouts/Girl Scouts ____School Club
Reason for joining Clubs:____________Fun_____________Learning____YMCA or YWCA__________Sports______Church Group______Other____________Other:___________________

Disclaimer :I have read the completed application. My child and I understand the rules of the Boys & Girls Clubs and request that my child be admitted intomembership. I understand the Open Door Policy allows my child to come and go at will and that the program is not a licensed day care center throughthe TDFPS. I give my consent for photographs of my child to be used in promotional materials by the Boys & Girls Clubs and their affiliates.

Parent’s/Guardian’s Signature: _____________________________________________Date:___________________FOR OFFICE USE ONLY
Membership #: ______________________

Amount Paid $_______________________________

Entry Date: _______________________

Expiration Date: _____________________

Date Paid: __________________________________

New/Renewal Member: ____________

Birth Certificate on File________________

Processed by: ________________________________