MEMBER INFORMATION:

1. Roosevelt Clubhouse Cabazon Anna Hause Central Brookside Coombs 2010/2011 MEMBERSHIP APPLICATION 3 Rings Ranch Hemmerling Sundance Hoffer Tournament Hills Nicolet MEMBER INFORMATION: Nick Name:______________________ Last Name:__________________________ First Name:______________________ African American Asian Caucasian Hispanic Native American Multi-Racial Other:____________________________ Please Circle Gender: M F Date of Birth:_________________ Ethnicity: Age:______ Address:__________________________________________________________ , ____________________ , CA ____________ Zip City Telephone:_______________________________________________ Email:_____________________________________________________________________________ TO RECEIVE CLUB NEWS Teacher:_____________________ School:_____________________________ Grade:_____ Number of people in household:______ $0-18,000 $18,001-24,000 $24,001-26,000 $26001-28,000 $28,001-41,500 over $41,500 Please Circle Does child receive Free Lunch at school? Household Income: Y N Mother Father Both Other:__________________________ Child lives with: Please Circle Circle All Programs That Apply: TANF SSDI SSI GENERAL ASSISTANCE FOOD STAMPS OTHER:_____________________________ PARENT / GUARDIAN 2: PARENT / GUARDIAN 1: Name:_______________________________________ Name:_______________________________________ Relationship:_______________ Employer:___________________ Relationship:______________ Employer:____________________ Telephone:_________________________ Telephone:_________________________ Home Cell Work Home Cell Work Please Circle Please Circle Telephone:_________________________ Telephone:_________________________ Home Cell Work Home Cell Work Home Cell Work Telephone:_________________________ Telephone:_________________________ Home Cell Work ADDITIONAL NAMES AUTHORIZED TO PICK-UP CHILD: EMERGENCY CONTACTS: Name:__________________________________ Relationship:_____________________________ Name:_______________________________ Home Cell Work Telephone:______________________________ Relationship:__________________________ Please Circle Telephone:______________________________ Home Cell Work Name:_______________________________ Name:__________________________________ Relationship:__________________________ Relationship:_____________________________ Name:_______________________________ Telephone:______________________________ Home Cell Work Please Circle Telephone:______________________________ Relationship:__________________________ Home Cell Work MEDICAL: Medication: Y N List Medication:_____________________________________ Please Circle Food Allergy: Y N List Food Allergy:_____________________________________ OFFICE USE ONLY: Date:_______________________ Staff Int:_______________________ Contact us at: (951) 922-3259 fax: (951) 922-2141 www.bgcsgpass.comadmin@bgcsgpass.com PO Box 655, Beaumont, CA 92223 Card #:_______________________

2. MEMBERSHIP APPLICATION PAGE 2 OF 2 PARENT / GUARDIAN CONSENT DISEASES HEALTH HISTORY ALLERGIES Frequent Ear Infections Ivy Poisoning Chicken Pox Bleeding/Clotting Disorders Hay Fever Measles Heart Defect/Disease Insect Stings German measles Convulsions Penicillin Mumps Diabetes Other Drugs Asthma MEDICAL RELEASE This health history is correct so far as I know and the person herein described has permission to engage in all prescribed Club activities except as noted by the examining physician and me. I hereby give permission to the physician selected to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named on this application. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. HOLD HARMLESS CLAUSE I further agree that the Boys & Girls Clubs of the San Gorgonio Pass, it’s Board of Directors, officers, staff and volunteers are hereby relieved of any and all liability, including but not limited to medical treatment, emergency transport or on-site assistance, in the event of accident or injury to the said minor. OPEN DOOR POLICY – DOES NOT APPLY TO SCHOOL SITES WHEN SCHOOL IS IN SESSION I understand the Boys & Girls Clubs of the San Gorgonio Pass has an “Open Door” policy that allows Club members to enter and leave the Clubhouse facilities as they choose. I understand that other adjacent areas outside the Clubhouse may not be supervised by the Boys & Girls Club staff, and because of the “Open Door” policy, my role as a parent determines where my child can play. Therefore, I agree that the Boys & Girls Club is not responsible for my child if they leave the Clubhouse premises. Also, I understand the Boys & Girls Clubs of the San Gorgonio Pass is not a licensed day care provider by its’ own choice. PUBLICIITY RELEASE I hereby consent to authorize the reproduction, publication and use the Boys & Girls Clubs of the San Gorgonio Pass and Boys & Girls Clubs of America, and their successors and assigns, for advertising, commercial, or any other purposes of any photograph picture or likeness of my child. CONSENT I have read and understand the above and hereby give my permission for my child to become a member of the Boys & Girls Clubs and to have my permission to participate in all the activities/programs offered by the Boys & Girls Clubs. I understand that my child must have good behavior and the Boys & Girls Club is a private organization and membership is a privilege and my be revoked at anytime. Additionally, I understand that the Boys & Girls Clubs is not responsible for the time or manner in which my child may arrive at or leave the Clubhouse, and that the Boys & Girls Club and its property are not responsible for personal injury or loss of property. Parent / Guardian signature: ____________________________________ Date: ___________________ Contact us at: (951) 922-3259 fax: (951) 922-2141 www.bgcsgpass.comadmin@bgcsgpass.com PO Box 655, Beaumont, CA 92223