Skip to main content

WEST HERNANDO MEMBERSHIP APPLICATION

Before & After School

2021-2022 SCHOOL YEAR MEMBERSHIP APPLICATION - Waitlist

 

Unit Name:
Fees and Attendance
Acknowledgment of Fees and Attendance Notice
Anticipated Start Date
Anticipated Membership Type
Membership Type:

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 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:

Upload Documentation as you feel necessary
No file selected

Close