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Membership information form
Head of househould
Name:
Address:
City:
State:
Phone:
work#:
Cell#:
Email:
Gender:
Family Size:
Family Income:
select one
12,000-15,000
15,001-19,000
19,001-23,000
23,001-28,000
28,001-32,700
32,701-37,500
37,501-42,000
42,000-above
9,001-12,000
9,000-below
deleted value
Employer:
Job Title:
Occupation:
Parents/Guardian
Name:
Address:
Phone:
Work#:
Email:
Gender:
Employer:
Member Information
Name:
Nick Name:
DOB:
Social Security#:
Gender:
School:
Grade:
Membership Type:
Select One
After School Care
Athletic Membership
Full Time
Summer Camp
Pick up Authorization Password:
Ethnicity:
Select One
African American
Causasian
Latino
South American
Asian American
Cuban
Multi Racial
Biracial
Hispanic
Native American
Other
Member Medical Information
Insurance Company:
Insurance Policy#:
Doctor:
Doctor#:
Medications:
Check all that apply:
Select One
TANF
Food Stamps
General Assistance
SSDI
School Lunch
Medicaid
Can Swim
Disabilities:
Allergies:
Two People Authorized to up member
First Person
Name:
Phone#:
Second Person
Name:
Phone#:
Payment Area
Membership fees:
Reg. Membership $25
Summer Membership $15
Sport Membership $10
Membership Handbook
Parents Handbook
