Membership Application All fields with a red asterisk need to be completed to move on to the next step of the form. Membership Application Step 1 of 7 14% What program are you intrested in?* Summer Program After-School Program Name must match school records* First Middle Initial Last Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Parent's Phone Numbers*Both fields need to be completed. If your home and cell are the same number, please enter the your cell phone and enter 'same' for home phone. Please enter 'none' if you do not have a number.Cell PhoneHome Phone Parent's Email Address* Birthdate* MM slash DD slash YYYY Gender* Male Female Race/Ethnicity*Black/African AmericaWhite/CaucasianHispanic/LatinoHawaiian/Pacific IslanderAsianNative AmericanBi-RacialMulti-RacialOtherWhat is your race/ethnicity? I've been a club member for*I'm a new memberLess than 1 year1-2 years2 or more yearsGrade during the 2020-2021 School Year* Name of School* Name of Teacher* Student ID If you do not have the student ID you can continue, but please know that we will need this information. Household InfoIs member from a single parent household?* Yes No Gender of head of household* Male Female Member Receives* Free Lunch Reduced Lunch Neither free or reduced lunch Member lives with*Both parentsMotherFatherAunt/UncleGrandparentsFoster CareOtherWho does the member live with? Military Household*No, not militaryAir ForceArmyCoast GuardMarine CorpsNavyDo you live on base? Yes No Member's Medical ProfileDoes member have any allergies or dietary religious restrictions?* Yes No Please check all that apply. Beef Pork Fish/Shelfish Milk/Dairy Products Peanuts/Peanut Butter Tree Nuts Wheat/Gluten Drug Allergy Other Provide the name(s) of the drug(s) member is allergic to What other food(s) is member allergic to? Does member take any prescription medication?* Yes No Please list the prescription medications member takes.Click the plus sign to add additional medications If prescription medications HAVE to be administered during Club hours, parents must complete additional medication form. We prefer to not keep medication at the Club. However, if it is necessary, it will be kept in a lock box.Do we have permission to transport your child, or call 9-1-1 in the event of a life-threatening emergency?* Yes No Does member have any special medical conditions?* Yes No Please check all that apply ADD/ADHD Diabetes Emotional/Behavior Disorder Epilepsy/Seizure Disorder Gastrointestinal Disorder Other Please list other special medication condition Primary Physician's Name* First Last Primary Physician's Phone*Do you have medical Insurance?* Yes No Insurance Company Insurance Policy Number Parent/Guardian InformationPrimary Parent* First Last Home Phone*Employer* Work PhoneOccupation* Do you receive vouchers from the housing authority or do you live in public housing?* Yes No Please list the name of the agency you receive assistance. Primary Parent Authorization* Primary Parent is Emergency Contact Primary Parent is Pick Up Person Neither Is there a secondary parent/guardian?* Yes No Secondary Parent/Guardian First Last PhoneHome PhoneEmployer Occupation Secondary Parent/Guardian Authorization Emergency Contact Pick Up Person Neither Emergency Contacts other than Parent/GuardianAdditional ContactsPlease list the names of other people who can be contacted in case of emergency. Click the plus sign to add up to 4 people.NameRelationshipPhone Authorized to pick up member from ClubPlease list the names of other people who can are authorized to pick up member from Club. Click the plus sign to add up to 4 people.NamePhone Authorized to leave premises unescorted* My child is younger than 13 years old but has my permission to walk/leave the Club with older siblings/friends listed in the authorized pick up list My child is 13 years or older but DOES NOT have my permission to check him/herself out of the Club My child is 13 years or older and has my permission to check him/herself out of the Club NOTE: if there are any legal situation regarding unauthorized pick-ups/visitations, please provide information to the Club (i.e. court orders).Additional House InfoNumber of Person in Family Unit (# in household)*Gross Annual Household Income (before taxes/deductions)* Media Permission Form RE: Use of Name, Photograph, Video and Identity in connection with Advertising and/or Promotion of the organization. For valuable consideration I, the undersigned, hereby irrevocably consent to and authorize the unrestricted use by Boys & Girls Club of Glacier Country and their subsidiaries, affiliates and advertising agencies (“Companies”) of my child’s name, photographs, videos, works of art and identity in various BGCGC website and collateral material, as well as miscellaneous print publications and other media outlets, and any personal information that I supply to the Companies, in connection with advertising and promotion of the Companies and/or their products in any media, form or material selected by the Companies, without any right of prior review or further approval, whether such advertising and promotion is to the public, to the trade, or both, and in the corporate releases, newsletters and other communications of the Companies; and I hereby waive, and release and discharge said Companies and all agents, employees and officers of the Companies, including their agencies, media producers and customers from, any claims, liabilities and demands, past, present or future, including any that I do not now know of or anticipate arising in the future, none of which would affect my execution of this release if known to me, and waive all rights with respect to such use of my name, photograph, identity, and personal information including but not limited to publicity, privacy, psychological injury and libel.Permission* I give my child Media Permission I DO NOT give my child Media Permission Media Permission Form By signing below, the parent/guardian of the youth agree that the boys & Girls Club of Glacier Country nor any of their representatives shall be held liable for any accidents or misfortunes while in route to or returning from any boys & Girls Club outings during the After-School/Summer Program. This includes outings in which members travel by foot off the Club property with Club staff for normal programming time (i.e. city pool, Glacier Institute, Glacier Gateway playground, etc.) The Boys & Girls Club of Glacier Country must have this permit signed by the parent/guardian before the youth is allowed to travel with the Club during any outings during the after-school/summer program. This form only gives permission for youth to travel with the Boys & Girls Club of Glacier Country. A parent/guardian signature must be on a sigh-up sheet for each field trip before the youth will be allowed to attend that field trip or outing. A youth may only attend field trips open to their age group. Some field trips may have limited capacity; these sign-ups will be on a first come, first served basis.Permission* I give my child General Travel Permission I DO NOT give my child General Travel Permission School Data Release The Boys & Girls Club of Glacier Country is the recipient of a federal grant for after-school and summer programs. As a recipient we have required reporting that is mandatory in order to be in compliance with the grant. By not collecting this data and providing accurate reports we could be at risk of losing funding through the 21st CLCC grant. By signing this form, you are giving permission to allow Columbia Falls School District 6 and the Boys & Girls Club of Glacier Country to share the following information: Boys & Girls Club of Glacier Country must share each member’s full name as listed on school enrollment, race/ethnicity, English Language Learner, IEP or 504 Status, date of birth, gender, free/reduced lunch eligibility, grade/teacher name with School District 6 to be flagged as a participant in after-school programming to Montana Office of Public Instruction. Several of the goals written in the grant are to provide programs that will assist Club members in excelling academically in school. The grant states we will have consistent communication throughout the school year with school administration and/or teachers to collaborate on how to help Club members who are struggling with grades. Club staff and school staff will share information about school work, report cards and Smarter Balance scores. Developing positive behavior in Club members is another goal written in the grant. Club staff and school staff will share excessive behavior issues in an effort to work together to address these issues and to carry over consistency from the school day to after-school programming to better serve Club members. If you have any questions or concerns please feel free to give me a call, Mandy Anderson, CEO, (307) 797-1189.Child's Name as provided to school* First Last Parent Signature*Today's Date* MM slash DD slash YYYY NameThis field is for validation purposes and should be left unchanged.