Annual Membership Registration Form

Boys & Girls Clubs of Snohomish County

 Any information requested is for our records and for the funding we receive. The answers you provide will be kept completely confidential. Your cooperation in providing this information is both appreciated and necessary. ALL FIELDS ARE REQUIRED. Please make sure to fill out this form in its entirety.

 Child’s Information

Eligible for Free or Reduced-Price School Lunch:
Ethnicity/Race: *

 Primary Parent/Guardian Information

Veteran or active member of the U.S. Military? *

Other Parent/Guardian Information

Veteran or active member of the U.S. Military? *

Household Information

Household Type:
Family Annual Income: *

Medical Information

Emergency Contacts

 Terms & Conditions: I declare that I am the parent or legal guardian of the minor listed above. I have full custody and control of the child. To the best of my knowledge, my child is in good health and is adequately immunized to participate in the Boys & Girls Clubs activities. In the event that my child is injured or should require medical attention, I hereby request you to contact our family physician. In the event that the Doctor cannot be reached, I hereby authorize his/her athletic supervisor, coach or any other Boys & Girls Clubs employee or volunteer to secure necessary medical treatment for my child. I further acknowledge that I will be responsible for any medical or hospital fees or costs associated with my child’s medical treatment. If possible, confirmation of this authorization should be made with me prior to treatment by calling me at the listed phone number. In case I cannot be reached for an emergency medical treatment as described above, you may proceed without further authorization. I understand that the Boys & Girls Clubs provide only a secondary Health Insurance coverage. I understand the “open door” policy which allows for children to come and go as they desire. I understand also that the Club accepts no responsibility for keeping my child in the building or on the premises, except when enrolled in a licensed childcare or summer camp program. I hereby give permission for a photo or likeness of my child to be used in brochures and other promotional materials produced by the Boys & Girls Clubs of Snohomish County. The photo will not be sold without the express written consent of the parent or legal guardian. I agree that this waiver is valid as long as my child is a member of the Boys & Girls Clubs of Snohomish County.

By checking this box, you are agreeing to the terms and conditions stated above *

For Office Use Only

Membership Type: