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BROOKSVILLE MEMBERSHIP APPLICATION

Before & After School

MEMBERSHIP APPLICATION

Unit Name:
Membership Type
Membership Type:

MEMBER INFORMATION

 

First Name
Middle Name
Last Name
Date of Birth:
Gender:
Ethnicity:
Address:
City:
State:
Zip Code:
Home Phone:
Cell Phone:
EMail:

SCHOOL INFORMATION

 

School:
Grade:
Lunch Level:

MEDICAL INFORMATION

 

Doctor's Name and Telephone Number
Does Member have any Serious Medical Issues?
This list should include all known allergies

PHYSICAL INFORMATION

Skin Color/Features:
Height:
Weight:

HOUSEHOLD INFORMATION

Member Lives With...
Number in Household:

*Primary Contact Name:
The primary contact will be the first person contacted with any concerns regarding member, member's account or in an emergency
Relationship to Member:
Information/Permissions
Select all that apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Information/Permissions
Select all that apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Information/Permissions
Select All That Apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Information/Permissions
Select All That Apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

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