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MEMBERSHIP APPLICATION - KEYSTONE CLUB

2022 Summer Camp

Keystone Club Membership Application

 

Unit Name
Unit Name:
Anticipated Start Date

MEMBER INFORMATION

The following information is required for membership at Boys & Girls Clubs of Hernando County.

This information will not be used individually but grouped and used for securing and maintaining local, state, and federal funding sources, including donations and grants. All information is held strictly confidential.

Please enter the following information for the Child you are enrolling as a Member of the Boys & Girls Clubs of Hernando County:

 

First Name
Middle Name
Last Name
Date of Birth:
Gender:
Racial Identity
Ethnicity
Address:
City:
State:
Zip Code:

SCHOOL INFORMATION

 

School:
Grade:
Lunch Level:

MEDICAL INFORMATION

 

Doctor's Name and Telephone Number
Please enter your initials indicating your agreement and understanding of the Authorization for Medical Care
Has Member been diagnosed with any of the following conditions:
Check all that apply
This list should include all known allergies, including food allergies

PHYSICAL INFORMATION

Skin Color/Features:
Height:
Weight:

HOUSEHOLD INFORMATION

Number in Household:
Military: Household member currently enlisted or have served
Current/Former Military?

Please identify Emergency Contact Information. In the event of an emergency, contacts will be called in the order you list them below. Also, if you do not authorize your child to sign themselves out of the program, you must identify at least one of the contacts as "authorized to pick up"

Please note that if there is a court order pertaining to a parent/guardian and contact with a member, you MUST provide a copy of the court order to the Unit Director.  We cannot, by law, restrict access to a child by a parent without a valid court order.  You may upload a copy of a court order using the upload button below, prior to submitting your application.

*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:

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:

Consent for Child to Leave the Program


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