Emergency Child Care for Core Services

*Please complete the application below for each member.

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* Member Information

Member's Name

M.I.

Last Name

Date of Birth

Address

City/State

ZIP/Postal Code

Phone Number

Email Address

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* Gender

Male

Female

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* Current BGCOKC Club member?

Yes

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* Ethnicity

White or Caucasian

Black or African American

Hispanic or Latino

Asian or Asian American

American Indian or Alaska Native

Native Hawaiian or other Pacific Islander

Multiracial

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* Member may participate in all Club activities in or adjacent to the club building?

Yes

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* Member has permission to be used in public relations materials i.e website, photos, media, print publications?

Yes

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* School Information

School

Grade Level

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* Parent Information

Name

Employer

Total Annual Income $

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* Military Family

Active

Retired

Branch of Military

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* Member Lives With

Mother

Stepmother

Father

Stepfather

Grandparent

Foster Parents

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* Medical Information

Insurance Provider

Serious Health Conditions

Medications

Permission for Treatment by Doctor/Hospital?

Allergies

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* Emergency Contact

Name

Employer

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* Emergency Contact

Name

Employer

Address

City/Town

State/Province

ZIP/Postal Code

Phone Number

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* Parents/Guardians understand that the Club closes at 7:30 pm. If a member remains at the club after 7:30 pm, the parent/guardian will be charged $1.00 per minute after 7:35. An invoice will be given to the parent at pickup and will need to be paid before the child returns to club.

If the parent/guardian who is picking up the club member appears to be impaired by drugs or alcohol, staff will contact another adult on the Registration Form. The club member may not be released to a parent/guardian under the influence of drugs or alcohol. The club member will remain in a staff’s care until the arrival of an authorized adult, who is capable of taking responsibility for the club member’s release.

Acknowledge

Question Title

* I do hereby give my son/daughter permission to become a member of the Boys & Girls Clubs of Oklahoma County and to participate in activities and programs. I hereby release the Boys & Girls Clubs of Oklahoma County, including its employees, associates and contributors, from liability from any injury, illness, loss, or theft incurred by my son/daughter while participating. Furthermore, I hereby authorize medical examination and emergency treatment for my son/daughter by a medical professional in the event of an accident or serious illness. My signature indicates that I completely understand the above statements and have received/reviewed the parent handbook.

Yes, I have read the above statement.

Electronic Signature

**A confirmation e-mail will be sent once child has been approved.