Boys & Girls Clubs of the Virginia Peninsula

Are you a :
New Member ___
Renewing Member __

Citizens Unit
1815 Shell Road, Hampton, VA 23661 (757) 244-6610

REGISTRATION FORM
PLEASE COMPLETE BOTH FRONT AND BACK
MALE ______

FEMALE ______ (check one)

CHILDS NAME: ________________________________________________________________________________________

FIRST

MIDDLE INITIAL

LAST

NICKNAME

DATE OF BIRTH ______________(if under 7, birth certificate required) AGE _____ PHONE: Home___________________
ADDRESS _____________________________________________________________________________________________
STREET & NUMBER

CITY

ZIP

FATHERS NAME _________________________________ MOTHERS NAME _____________________________________

FATHERS EMPLOYMENT __________________________ MOTHERS EMPLOYMENT _____________________________
FATHERS PHONE: Work _____________Cell ____________ MOTHERS PHONE: Work _____________Cell _____________
NAME AND ADDRESS OF TWO EMERGENCY CONTACTS IF A PARENT CANNOT BE REACHED:
1. NAME _________________________________ ADDRESS ___________________________ PHONE ________________
2. NAME _________________________________ ADDRESS ___________________________ PHONE ________________
SCHOOL _______________________________ GRADE _______ ESTIMATED HIGH SCHOOL GRADUATION ___________
Is the child eligible or receiving free lunch? ___YES ___NO

Is the child eligible or receiving reduced lunch? ___YES ___NO

LIST CHRONIC PHYSICAL PROBLEMS AND DEVELOPMENTAL DELAYS, IF ANY: _________________________________

____________________________________________________________________________________________________
AGREEMENT BETWEEN PARENT AND BOYS & GIRLS CLUBS OF THE VIRGINIA PENINSULA
1. I hereby give my authorization to the Boys & Girls Clubs of the Virginia Peninsula to provide for emergency medical care
when I cannot be located immediately.
2.
The Boys & Girls Clubs of the Virginia Peninsula will notify me when my child becomes ill and I will arrange to have my child
picked up as soon as possible.
3. If the Boys & Girls Clubs of the Virginia Peninsula decides to terminate the enrollment of my child, they will provide to me in
writing the reason(s) for termination.
4. I understand that it is the Clubs desire that members stay in the building, even though they are free to enter and leave the
premises without permission or supervision. I will instruct my child as to whether or not they may leave the Club.
5. I hereby give my permission to Boys & Girls Clubs of the Virginia Peninsula to photograph/videotape my child for public
relations and/or educational purposes. Furthermore, it is understood that my child may be included in programs or news
stories that are released to the local media.
6. I hereby give my permission to Boys & Girls Clubs of the Virginia Peninsula to collect information from my child's school
regarding their grades and any other relevant information.
7. I give permission to the Boys & Girls Clubs of the VA Peninsula to collect information about their club experience via online
or written surveys, questionnaires, interviews, and focus groups from the minor listed on this application. Any and all
information received will be kept strictly confidential. The results will be shared with Club staff, Boys & Girls Clubs of America
(BGCA), funders and other community stakeholders to evidence program effectiveness and/or club impact on our members.

_______________________________________________

___________________________________________

SIGNATURE OF PARENT OR GUARDIAN

DATE

______________________________________________________________________________________________________
**FOR UNIT DIRECTOR USE ONLY DO NOT WRITE IN THIS SPACE**
DATE JOINED _____________ FEE PAID __________ CLASS ____________ CLUB # __________ REG. BY __________

BOYS & GIRLS CLUBS OF THE VIRGINIA PENINSULA

Please complete the following demographics information for your child. This information is required for our
Federal Funding Reporting Requirements and will be tabulated with all other data received. Your personal
information will be kept strictly confidential.
Single-parent Family:

____yes

____no

Who does the child live with?_______________________________

# of brothers _______

# of sisters ________

Race/Ethnicity: (check appropriate box)

Asian

Asian/Pacific Islander

Asian & White

American Indian/Alaskan Native

Black/African American

American Indian/Alaskan Native & Black

Black/African American & White

Hispanic

American Indian/Alaskan Native & White

White

Other Multi-Racial ________________

Native Hawaiian/Other Pacific Islander

(check appropriate box)

Two

Three

Four

Five

Six

Seven

Eight

Nine

Ten

Household Income: (check appropriate box)

$0 - 17,235

$35,326 - 41,355

$17,236 - 23,265

$41,356 - 47,385

$23,266- 29,295

$47,386 - 53,415

$29,296 - 35,325

$53,416 - 59,445
$59,446 and up

I confirm the above is true and correct.

_______________________________
Parent Signature
ALL OF THE ABOVE INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL.

Family Size:
Number in
Household