Boys & Girls Club of New Britain PID __________________________________ 150 Washington Street DATE OF APPLICATION____________________ New Britain, CT 06051 MEMBERSHIP #__________________________ NEW___RENEW___AMT.$____________________ ETH. W___B___H__O__STAFF________________ CLASS: PEEWEE____MIDGET_________________ JUNIOR____CADET____SENIOR________ EXPIRES_____________________________ 20 __ MEMBERSHIP APPLICATION
LAST NAME______________________________________FIRST NAME______________________________ MI_______
ADDRESS_____________________________________________________________ HOME PHONE ______________
DATE OF BIRTH__________________ AGE_________ SEX_____ BIRTHPLACE_________________________________
ETHNICITY: WHITE____ BLACK___HISPANIC___OTHER____ SOCIAL SECURITY#_______________________________
NAME OF SCHOOL_____________________________________________ GRADE________________
DO YOU KNOW HOW TO SWIM? YES □ NO □
WITH WHOM DO YOU LIVE? Both Parents □ Mother □ Father □ Guardian □
HOW MANY? Sisters____________________ Brothers ________________
Mother’s Name:_______________________________________________ Home Phone: __________________________ Place of Employment ___________________________________________Work Phone: __________________________
Father’s Name:________________________________________________Home Phone:________________________ Place of Employment____________________________________________ Work Phone: ________________________
Guardian’s Name:______________________________________________ Home Phone:________________________ Place of Employment ___________________________________________Work Phone:__________________________
Do you have any physical limitations or medical problems? YES □ NO □ If yes, please describe ___________________________________________________________________________________________________
Are you taking any medication? Yes □ No □ If yes, list medication _______________________________________________
* I understand that if I do not check “no” in the box below, I give my permission for the Boys & Girls Club of New Britain, Inc. to photograph my child in club activities for use in literature and mass media. NO □ I do not give permission to have my child photographed.
MEMBER: I promise to take care of my club and its property, to allow no one to use my card, as it is for my use only, and to be loyal to my club.
MEMBER SIGNATURE_________________________________________________________________
PARENT: By signing this application I give my child permission to join the Boys & Girls Club of New Britain, Inc. and fully understand and agree to the Boys & Girls Club’s open door policy which states that my child can enter or leave the Boys & Girls Club of New Britain, of his/her own accord, at any time and the Boys & Girls Club of New Britain will not be held accountable. I also understand that the Boys & Girls Club of New Britain will be responsible for my child while he/she is in the building and/or on the grounds of the Club.
