Keystone Club : Find a Club : Boys & Girls Club of Hernando County

Are you a high school student aged 16-18? Do you want to lend a helping hand to improve kids’ lives?

From making our daily functions run more smoothly to getting directly involved in the youth we serve, you have what it takes to make a difference. As a Keystone Club member you will develop interpersonal skills, a strong work ethic and a sense of community engagement while experiencing on-the-job Club Work. In addition, your work will count towards Community Service hours necessary for Graduation, College Applications and Scholarships.

Once you have completed the application below, please have a parent/legal guardian return and complete the Membership Application by selecting the button below.

Keystone Club Application

I would like to be a Keystone Club member during:

School Year
Summer Camp

I would like to be a Keystone Club member at:

Westside Unit
Brooksville Unit
Moton Unit
West Hernando Unit
Winding Waters Unit
Westside Summer Camp
J.D. Floyd Summer Camp
Brooksville Summer Camp

First Name (Required)

Last Name (Required)

Birth Date

Email (Required)

Phone (Required)

Address (Line 1) (Required)

Address (Line 2)

City (Required)

State (Required)

Zip (Required)

Parent or Legal Guardian Name: (Required)

Parent or Legal Guardian Name:

Phone Number: (Required)

Area(s) of Interest (Required)

EDUCATION:

Grade Level:

School Name:

Years Attended:

GPA:

Previous Work/Volunteer Experience:

Hobbies/Sports/Extracurricular Activities:

Awards/Achievements:

SCHEDULE/AVAILABILITY:

Days Available

Monday
Tuesday
Wednesday
Thursday
Friday

Hours Available

Anytime
Morning (9:00am - 12:00 noon)
Afternoon (12:00 noon - 5:00pm)
Evenings (5:00pm - 9:00pm)

Availability

Ongoing Availability
Limited Availability

If Limited Availability, please indicate dates

Have you ever been convicted of a criminal offense?

4g82tntxsbnq

Do you have Physical Limitations?

Do you have any physical limitations or are you under any course of treatment which might limit your ability to perform certain types of work?

If yes, please describe

REFERENCES:

Please provide 3 non-relative references.

Name (Required)

Address (Required)

Phone: (Required)

Relation (Required)

Name

Address

Phone

Relation:

Name

Address

Phone

Relation

Electronic Signature

Understanding & Authorization I hereby attest that the above information is true to the best of my knowledge and that I am not withholding any pertinent information. I agree to the administration of a background check and I authorize the Boys & Girls Club of Hernando County to investigate all information in this application. I also authorize educational institutions and employers listed within this information sheet to give the Boys & Girls Club of Hernando County information concerning my education, employment, and fitness to work with children and young people.

Please enter your initials. This will act as your electronic signature.

Date Signed