Pamplico Membership Application : Clubs : Who We Are : Boys and Girls Clubs of the Pee Dee Area

Register for Pamplico Club Fall Programming

Use this form to register child for Club programming. Please fill out additional registration forms for any additional children.

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Club Member Name

First Name *

Last Name *

Birthdate

Month

Day

Year

Club Member(s) Information

Male/Female

Male
Female

Race

Asian
Black
Caucasian
Haitian
Hispanic
Native American
Other

School (Required)

Grade (Required)

Describe who the youth lives with:

Both Parents
Mother Only
Father Only
Grandparent
Foster Parent
Other

Guardian 1

First Name *

Last Name *

Relationship to Club Member

Mother
Father
Other

If other, please specify (Required)

Home Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Email (Required)

Cell Phone Number (Required)

Work Phone Number

Home Phone Number

Guardian 2

First Name *

Last Name *

Relationship to Member

Mother
Father
Other

If other, please specify (Required)

Home Address

Country

Address Line 1 *

City *

State/Province *

Postal Code *

Email (Required)

Cell Phone Number (Required)

Work Phone Number

Home Phone Number

Emergency Contact #1

First Name *

Last Name *

Phone Number (Required)

Alternate Phone Number (Required)

Email (Required)

Emergency Contact #2

First Name *

Last Name *

Phone Number (Required)

Alternate Phone Number (Required)

Email (Required)

Medical Release

I give permission to the Boys & Girls Clubs of the Pee Dee Area to seek emergency medical treatment for my minor child(ren) listed above if I cannot be reached. I hereby authorize the attending physician, in an emergency situation, to perform whatever acts that is his/her professional opinion are in the best interest of my child. I will be responsible for any/all costs of medical attention and treatment.

By checking this box, I understand and agree to the terms that have been stated above

Parent/Guardian 1 Name

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature

First Name *

Last Name *

Relationship to Club Member (Required)

Date

Month

Day

Year

By checking this box, I understand and agree to the terms that have been stated above

Parent/Guardian 2 Name

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature

First Name *

Last Name *

Relationship to Member (Required)

Date

Month

Day

Year

Publicity Release

I hereby consent to the reproduction, publication and use of photographs or video taken of my child(ren) listed above, items (artwork, photos, videos, etc.) submitted to the Boys & Girls Clubs of the Pee Dee Area can be used for advertising, educational and/or publicity purposes in any and all publications, advertisements and publicity materials, without limitation or reservation. I also consent to any use of testimony or copy written by or about my child that may accompany said photographs or stand alone in any and all publications, advertisements and publicity materials, without limitation or reservation.

By checking this box, I understand and agree to the terms that have been stated above

Parent/Guardian Name

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature

First Name

Last Name

Relationship to Club Member

Date

Month

Day

Year

Memorandum of Agreement

I/we, the parent(s)/guardian(s) of the child/children listed above understand that the Boys & Girls Clubs of the Pee Dee Area, Inc. makes available organized educational and recreational activities for its’ members. I/we understand that there are always dangers and risks connected in participation in such activities (particularly athletics) and, as Parents/Guardians of the child named above, I/we hereby give my/our approval of his/her participation in all activities of the club. I/we understand that responsibility for any and all such risks and dangers (including any risks associated with the transportation to or from the Club or any club activity) and I/we do hereby release, indemnify and hold harmless the Boys & Girls Clubs of the Pee Dee Area, Inc. and Boys & Girls Clubs of America, the organizers, sponsors, supervisors and staff of all its’ activities, from any and all liability in connection with any injury (including any injury caused by their own negligence) to the child named above. I/we likewise release and hold harmless from liability any person transporting him/her to or from any club activity.

I/we agree to adhere to the policies and procedures of the Boys & Girls Clubs of the Pee Dee Area, Inc. which are in place for staff, youth, parents, and visitors.

I/we understand it is my/our responsibility to insure my/our child adheres to the club rules and follows staff instructions. Inappropriate behavior, not following rules and staff instructions can result in my child’s suspension or expulsion from the Club. If suspended or expelled, I agree to pick up my child immediately from the Club. I also understand any fees paid will not be refunded if my child is suspended or expelled.

I/we agree to be financially responsible for any property damage or loss caused by my child from inappropriate behavior.

I/we understand that the Boys & Girls Club has a non-refundable membership fee.

I/we understand a late fee of $5.00 every 15 minutes will be charged for any child left after the club closes and this fee must be paid before a child returns to the club.

I/we understand my/our child’s successful participation at the Club can be enhanced with my active participation at the Club. If I have a question, concern or comment about the Club or my child’s behavior I will direct my question to the Club’s director.

By checking this box, I understand and agree to the terms that have been stated above

Parent/Guardian Name

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature

First Name *

Last Name *

Relationship to Club Member (Required)

Date

Month

Day

Year

School Information Release

I give my permission to Boys & Girls Clubs of the Pee Dee Area and my child's school or respective School District to exchange information regarding the minor child(ren) listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student succeed in school, in Boys & Girls Club, and in life. This release is valid for one year and may be revoked at any time by contacting the School District or Boys & Girls Club in writing.

By checking this box, I understand and agree to the terms that have been stated above

Parent/Guardian Name

By entering your name, you agree to the terms and conditions set forth, and your name will serve in place of a signature

First Name *

Last Name *

Relationship to Club Member (Required)

Date

Month

Day

Year

Clubs

Register for Pamplico Club Fall Programming

Use this form to register child for Club programming. Please fill out additional registration forms for any additional children.

Club Member(s) Information

Medical Release

Publicity Release

Memorandum of Agreement

School Information Release

PLEASE NOTE PRIOR TO SUBMITTING PART II OF APPLICATION WILL BE EMAILED TO YOU FOR COMPLETION

Our Partners

Clubs

Register for Pamplico Club Fall Programming

Use this form to register child for Club programming. Please fill out additional registration forms for any additional children.

Club Member(s) Information

Medical Release

Publicity Release

Memorandum of Agreement

School Information Release

**PLEASE NOTE PRIOR TO SUBMITTING** PART II OF APPLICATION WILL BE EMAILED TO YOU FOR COMPLETION

Our Partners

PLEASE NOTE PRIOR TO SUBMITTING PART II OF APPLICATION WILL BE EMAILED TO YOU FOR COMPLETION