South Portland Member Registration

Member Info

MEMBER INFORMATION

Member Name:

Street Address:

City

Home Phone

Best number to receive text updates:

Member Email (if over 13):

Member Cell Phone (of over 13):

Ethnicity/Race

American Indian or Alaska Native

Asian

Black or African-American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Some Other Race or Ethnicity

Two or More Races

Gender

Member Birthdate:

How well can the Member swim?

Good

Fair

Poor

Not at all

Primary Language at Home

Member lives primarily with: (check all that apply)

Transportation is available in a limited capacity; please inquire with your Clubhouse for details.

Medical Info

MEDICAL INFORMATION

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

Other Medical Conditions:

Does the Member have allergies or dietary restrictions?

Please check all that apply:

Please list any medications currently used by the member:

Preferred Hospital or Clinic

Preferred Hospital of Clinic Phone

If your child is eligible, have their received their COVID-19 vaccine?

Yes

No

Prefer Not to Answer

School Info

SCHOOL INFORMATION

School Name:

Grade Starting Fall 2022:

School Cooperation Release

SCHOOL COOPERATION RELEASE

School Coop Release Opt-In

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 request access to the member’s school records as needed in order to receive information regarding attendance, grades, behavior in class and academic success. 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.

Parent/Guardian Info

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:

Relationship to Member:

Parent/Guardian Address

Parent/Guardian Phone

Parent/Guardian Email

Preferred Method of Contact:

Phone Call

Text Message

Email

Parent/Guardian Name

Relationship to Member

Parent/Guardian Address

Parent/Guardian Phone

Parent Guardian Email

Preferred Method of Contact

Phone Call

Text Message

Email

Emergency Contact Info

EMERGENCY CONTACT INFORMATION

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

Emergency Contact's Relation to Member

Emergency Contact Phone number:

Emergency Contact Address

INCOME INFORMATION

INCOME INFORMATION

Income Info

OPTIONAL: The responses to the following information are essential in maintaining and securing funding. Your cooperation is greatly appreciated and all responses will be kept confidential. Thank you!

Does the member/family receive any of the following:

Free/Reduced price lunc

SNAP

TANF

Child Care Assistance

How many members in your household including yourself?

Annual Household Income (Check One):

PUBLIC RELATIONS RELEASE

PUBLIC RELATIONS RELEASE

Public Relations Release

I give permission for the member listed on the application to have their name and/or pictures, portraits or such images, audio and/or video in advertising, news, social media, and/or any other promotional materials for Boys & Girls Clubs of Southern Maine (BGCSM), and for use or distribution in other non-BGCSM publications, electronic or otherwise, without notifying me. I waive any rights that I may have to inspect and/or approve the finished product that I or the member may have, including copyright. I agree to hold BGCSM harmless from any liability that may arise by virtue of any artistic or other distortion and/or alteration that may occur in the finished product.

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.

Member Registration
South Portland Clubhouse

South Portland Membership Application

Stay Connected

Main Offices

Member RegistrationSouth Portland Clubhouse

South Portland Membership Application

Stay Connected

Main Offices

Member Registration
South Portland Clubhouse