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Member Application
Personal Details
First Name *
Last Name *
Emergency Contact *
Emergency Phone *-- Extn.
Date of Birth *
Preferred location
Gender Male Female
Member Status New Member
Renewing Member
Former Member
Non-Member
School
Grade
Ethnicity African American
Asian American
Hispanic
Native American
Other
Street Address *
City *
Zip code *
Home Phone *--
Family Background
Name of Person Member lives with
Father/Guardian First Name
Father/Guardian Last Name
Father's Work Phone --
Father's E-mail Address
Mother/Guardian First Name
Mother/Guardian Last Name
Mother's Work Phone --
Mother's E-mail Address
Who does your child live with? Both Parents Mother Only Father Only Grand Parents Only Other
List all medications your child is currently taking
Has your child been a member of Boys & Girls Club previously? Yes
No
The following information is necessary for our records and the funding our organization receives. The answers you provide are completely confidential. Your cooperation in providing this information is both appreciated and necessary.
I, the undersigned applicant, do hereby authorize the Boys & Girls Clubs of Collin County to verify my personal records, including wages, pensions and investments. It is understood that this authorization is granted for the sole purpose of certifying my eligibility for federal assistance and that all information acquired in this regard will remain confidential.:
By clicking below to register, I acknowledge that all information I have provided is true and correct to the best of my knowledge. I am aware that making a false statement to obtain benefits to which I am not entitled is a crime and may be subject to both civil and criminal penalties.
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