Join
the Boys & Girls Clubs of Delaware County

Ready to Join?

Don’t miss out on the fun and growth opportunities at the Boys & Girls Clubs of Delaware County! Whether you’re looking to boost your academic skills, explore new hobbies, or make lifelong friends, our clubs offer something for everyone.

To initiate your Membership, please complete the form provided below or visit your local Club location to obtain a paper form.

Child Information

All Answers Required

Club Location

First Name *

Middle Name

Last Name *

Nickname

Birth Date *

Month *

Day *

Year *

Age *

Gender *

Ethnicity *

If Native American, Tribe:

School *

Current Grade *

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Parent/Guardian Information

Parent/Gardian Name(s) *

Mailing Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Physical Address (if different from mailing)

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Daytime Phone *

Cell Phone

Work Phone

Email Address *

Employer

Member Lives With: *

If "Other" Guardian, title:

Current Head of Household *MaleFemale

Single Parent *YesNo

Total Residents in Household *

Annual Household Income *

Emergency Contacts/Medical Information

Name *

Phone *

Doctor Name *

Doctor Phone *

Permission for Treatment by Doctor/Hospital: *YesNo

Medicaid *YesNo

Does your family have health and/or accident insurance: *YesNo

Insurance Carrier

Policy #:

Group #:

Serious Health Problems: *YesNo

If "Yes" Please Explain

Medications *YesNo

If "Yes" Please Explain

Child Release Authorization

Authorized to Pick Up Child *

DO NOT Allow Child to Go With

General Information

Member/Contacts Understood Signed Insurance Disclaimer and Permission Statement: *YesNo

Member has permission to be used in public relations materials: *YesNo

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

Parents/Guardians Acknowledge and Understand the Club Member Attendance Policy: *YesNo

Additional Information

Please enter any additional information

DISCLAIMER

The Boys & Girls Clubs of Delaware County, and its affiliates, are not responsible or liable in any way in the event of harm or injury occurring to the member. It is agreed that the parent or guardian will not hold Boys & Girls Clubs of Delaware County responsible for the welfare or whereabouts of the member. If the Parent or Guardian does file a complaint against the Club the Parent or Guardian agrees to pay for Boys & Girls Club of Delaware County’s legal fees.

MEDICAL RELEASE

I give the Boys & Girls Clubs of Delaware County my release to secure medical attention for my child as necessary, including transportation to medical facilities. If an emergency arises, I understand that Club personnel will try to contact me and my alternate contacts, but I release this right to them in the event of my being unreachable. I understand and approve of the procedures the Club has set for emergencies, and wish for them to take the necessary action to maintain my child’s health.

AGREEMENTS

I understand that:

- If I bring my child to the Club, I will need to sign them in. If my child arrives on their own, they must sign themselves in.
- My child should be signed out by an adult in order to leave the Club. Once my child has signed out, the Club is no longer responsible for my child.
- Youth are not allowed to use the Club phone to make “visiting”, overnight, or other arrangements, as this can lead to confusion on the part of the parents as to the location of their child.
- I am taking full responsibility for any damage that my child may be responsible for - full or in part - and that I will be held financially accountable for those damages.

Parent/Guardian Signature *

Start signing your signature here

Member Signature *

Start signing your signature here

Parent & Member Handbook Acknowledgement Form

**Form must be completed and returned before membership is activated.

I have received the Parent & Member Handbook packet and completed a membership enrollment form. By enrolling my child as a member of the Boys & Girls Clubs of Delaware County, I agree to adhere to and abide by the policies of the Club as stated in the Parent & Member Handbook. I also agree that my child, if between 7-11 years of age, will be enrolled in our TRAIL Diabetes Prevention Program and take part in the Smart Moves program. Ask your unit director for more details regarding TRAIL and Smart Moves. A copy of the Boys & Girls Clubs of Delaware County’s Parent & Member Handbook and Safety Policies are available by download at bgcofdc.com

Parent/Guardian Signature *

Start signing your signature here

Children

Child's Name

Jointhe Boys & Girls Clubs of Delaware County

Ready to Join?

Child Information

All Answers Required

Parent/Guardian Information

Emergency Contacts/Medical Information

Child Release Authorization

General Information

Additional Information

DISCLAIMER

MEDICAL RELEASE

AGREEMENTS

Parent & Member Handbook Acknowledgement Form

Join
the Boys & Girls Clubs of Delaware County