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BOYS & GIRLS CLUB OF PEKIN MEMBERSHIP APPLICATION DATE

MEMBER #

Member Information First Name Age Gender School

Last Name Birth Date Ethnicity Grade

TANF or SSI ____ Yes ____ No Child lives with _____ Mother

Free or reduced lunches ____Yes _____ Father

_____ Both Parents

Head of Houshold Parent/Guardian First Name Address City, State & Zip Employer

Last Name Phone 1 Phone 2 Occupation

Other Parent/Guardian First Name Address City, State & Zip Employer

Last Name Phone 1 Phone 2 Occupation

Member Medical Information Insurance Co Medications Medical Conditions Physician Hospital

____No

Optional Information Family Income Family Size E-mail Address

Is either parent/gaurdian a member of the military service? Yes _____ No _____ If so, which branch - Air Force _____ Army _____ Coast Guard _____ Marines _____ Navy _____ Active Status - Active _____ National Guard _____ Reserve _____ Retired _____ Discharged _____ I have completed the application, understand the rules of the Boys & Girls Club of Pekin and request that my child be admitted into membership. I explained the rules to my child and agree that the Boys & Girls Club of Pekin will not be held responsible for any accident or injury to my child while on the club premises or while engaged in any of its activities away from the Club. It is understood that each member should carry their own personal or company group insurance that will cover all accidents or injuries sustained. I do hereby waive any and all claims against the Boys & Girls Club of Pein, Board of Directors and Staff. I (we) hereby consent to allow the use of print and online publications for promotion of the Boys & Girls Club of Pekin activities and events.

__________________________________ Signature of Parent or Guardian

______________________________ Date


Membership Application