Club Application Form


Member Information:


Site Location or Program Name:*
Name:*
Middle Name:
Nickname:
Birth Date:*
Age:*
Sex:*
Ethnicity:*
Address:*
Phone:*
-

School Information:


Current School:*
Current grade:*
Current Teacher:
IEP Record Release:*
Free or Reduce Lunch:*
Preferred Activity:
High School Graduation Year:

Emergency contacts/Authorized to pick up child:
I give my consent to the Boys & Girls Club of Greater Holyoke Inc. to release my child to the following persons (other than parent/guardian)authorized to take my child from program or received child at the end of the day:

First Contact Name:*
First Contact Pickup/Emergency:*
First Contact Relationship:*
First Contact Phone:*
-

Medical Information:

Doctor Name*
Doctor Address:
Doctor Phone:
-
Child’s Insurance Carrier:
Policy #:
Group #:
Serious Health Problems:*
Medication needed:*
If yes, explain:
Recaptcha Word Verification: