2024-2025 Membership Application

Thank you for completing our Club Membership application! Please complete all parts of the application. Applications must be completed in full before services are rendered.

CLUB MEMBER INFORMATION

SCHOOL INFO

Food Allergies

Environmental Allergies

Medicine Allergies

Other Allergies

MEDICAL INFORMATION

Diagnosed Medical Conditions

INSURANCE

AUTHORIZED EMERGENCY CONTACTS

Authorized Contact 1

Authorized Contact 2

CAREGIVER PRIMARY CONTACT

Caregiver Military Status

Household Support

WAIVERS & RELEASES

I give my permission for Boys & Girls Clubs of Greater Cincinnati to collect information via online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any and all information received will be kept strictly confidential. Data gathered through these means will be summarized in the aggregate and exclude all references to individual responses. The aggregated results of these analyses may be shared with Club staff, BGCGC, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members. This release may be resolved at any time by contacting the Boys & Girls Clubs of Greater Cincinnati in writing

I give permission to the Boys & Girls Clubs of Greater Cincinnati to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment.

As a member of the Boys & Girls Clubs of Greater Cincinnati, our child may have access to the internet. While the Boys & Girls Clubs of Greater Cincinnati has rules prohibiting such conduct and precautions are taken by the Club to prevent such access, it is possibly your child may access inappropriate sites. Boys & Girls Clubs of Greater Cincinnati will not be responsible for such unauthorized access.

Parents and Club members may be responsible for their own transportation to and from the Club, unless otherwise specified. I understand that written permission is required for Boys & Girls Clubs of Greater Cincinnati to transport my child.

I give my permission to the Boys & Girls Clubs of Greater Cincinnati to share information about the minor child listed on this application with BGCGC for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCGC may include the information provided on this membership application form, the information provided by the minor child’s school or school district, and other information collected by Boys & Girls Clubs of Greater Cincinnati, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential. This release may be revoked at any time by contacting the Boys & Girls Clubs of Greater Cincinnati in writing.

I give my permission for my child’s picture, video image, or any other graphic depiction or likeness, to be used by Boys & Girls Clubs of Greater Cincinnati, Boys & Girls Clubs of America and its affiliates or donors and acknowledge neither my child nor I will receive payment for same.

I understand that the Boys & Girls Clubs of Greater Cincinnati is not responsible for lost or stolen items. Each Club has the right to make membership decisions based on the resources and capacity of their facility and staff. Boys & Girls Clubs of Greater Cincinnati reserves the right to decline the application, rescind the enrollment of, or suspend any youth that cannot successfully associate with other club members.

APPLICATION APPROVAL

I understand the Boys & Girls Clubs of Greater Cincinnati has an open door policy where members are allowed to come and go as they please. Should a member leave the Club, they will not be granted return access unless approved by the Club Director. We assume no responsibility for members who choose not to attend on a particular day or who choose to leave early. I, the parent/guardian of the minor child listed on this application, on behalf of the minor child listed herein and for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Clubs of Greater Cincinnati Boys & Girls Clubs of America (BGCA), their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club. Your signature below confirms that all information above is true and accurate.