Boys and Girls Club of Southern Maine

Important

IMPORTANT: Click the red button above to download and review our Covid-19 policy.

COVID-19

By checking, I attest that I have read and agree to adhere to Boys & Girls Clubs of Southern Maine's Covid-19 safety policies and procedures.

Member Info

MEMBER INFORMATION

Member Name:

Member Street Address:

Member City:

Member Email (if over 13):

Member Birthdate:

Select Your Clubhouse

Ethnicity/Race

American Indian or Alaska Native

Asain

Back or African American

Hispanic of Latino

Native Hawaiian or Pacific Islander

Other Race or Ethnicity

Two of More Races

Gender

Member lives primarily with (check all that apply):

Primary Language at Home

Does Member know how to swim?

Yes

No

Medical Info

MEDICAL INFORMATION

Does the Member have any of the following medical conditions? (Check all that apply.)

ADD/ADHD

Asthma

Diabetes

Cerebral Palsy/Other Motor Condition

Epilepsy/Seizure Disorder

Emotional/Behavioral Disorder

None of the Above

Other Medical Conditions:

Does the Member have allergies or dietary restrictions?

Yes

No

Check all that apply:

Please list any medications currently used by the member:

School Info

SCHOOL INFORMATION

School Name

Current Grade:

School Cooperation Release

SCHOOL COOPERATION RELEASE

As the Member's parent/guardian I give my permission to the Boys & Girls Clubs of Southern Maine to release the Member’s name listed on this application to their school in order to receive information regarding attendance, behavior in class and academic needs. The purpose of this is to help the organization do a better job of helping the member be successful in school, in the Boys & Girls Club and in life.

Yes

No

Parent/Guardian Info

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:

Parent/Guardian Phone

Parent/Guardian Email

Relationship to Member

Preferred Contact Method

Phone Call

Text Message

Email

Is the Parent/Guardian an Employee of South Portland School Department?

Yes

No

Emergency Contact Name (if parent/guardian cannot be reached):

Emergency Contact Phone Number:

Optional Income Questions

Responses to the following four questions are critical to securing and maintaing funding for BGCSM. Your input is greatly appreciated. Your responses are confidential.

Thank you!

Is the member a resident of Maine and a citizen, U.S. National, legal alien, or permanent resident?

Yes

No

Does the member/family receive any of the following:

Free/Reduced Price Lunch

SNAP

TANF

Child Care Assistance

How many members in your household including yourself?

Annual Household Income:

Public Relations Release

PUBLIC RELATIONS RELEASE

PR Release

By checking this box I agree to the statement listed above,

Parent/Guardian Agreement

PARENT/GUARDIAN AGREEMENT

Parent/Guardian Release

I hereby give my permission for my child to become a member of Boys & Girls Clubs of Southern Maine (BGCSM). I understand that BGCSM and its personnel are not responsible for personal injury or loss of property. I hereby give permission to BGCSM to secure proper treatment for my child in case of emergency. I understand that there is a BGCSM Parent & Member Handbook that provides guidelines my child and I must adhere to. I may request a copy of the handbook at any time.

By initialing below, I agree to submit my form responses.

Member Agreement

MEMBER AGREEMENT

I wish to become a member of Boys & Girls Clubs of Southern Maine. I promise to take care of my Club and its property, to allow no other person to have or use my card and to be loyal to my Club. I commit to being a positive member of my Club.

Summer 2021 Membership Application

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