Club Membership Form

All memberships renew on September 1, 2017

First Name:
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Last Name:
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  Gender:



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Address:
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City:
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State:
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School:
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Grade:
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Zip Code:
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Age:
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Birthdate:
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Total number of individuals living in your home: A value is required.Invalid format.
Home Phone:
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I live with:








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Race / Ethnicity:







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The following information is REQUIRED for the Club to obtain as a Non-Profit Agency and to keep our fees low.
This information is completely confidential. Your cooperation in providing this information is both necessary and appreciated.
Family Income:



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Does your child qualify for free/reduced lunch program?


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Does your household qualify for TANF?


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Name of Father/Guardian I live with:
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Email:
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His employer:

Work Phone:
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Cell Phone:
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Name of Mother/Guardian I live with:
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Email:
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Her employer:

Work Phone:
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Cell Phone:
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In Case of Emergency when Parents/Guardians are not available:
Please Notify:
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Relationship:
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Phone:
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Does this child have any physical condition, health problem, or take any medications that our staff should be aware of?


Please make a selection.
If yes, please explain

I have read the completed application, understand the rules of the Terre Haute Boys & Girls club and request that my son/daughter be admitted to membership. I have explained the rules to my son/daughter and agree that the Terre Haute Boys & Girls Club will not be responsible for any accident on the premises to the boy/girl while at the Terre Haute Boys & Girls Club or while engaged in any of its activities away from the Terre Haute Boys & Girls Club. I give my consent for photographs, in which my son/daughter may appear, to be used in any way the Terre Haute Boys & Girls Club may care to use them.

Accept Please make a selection.

Your Name: A value is required.

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