1001 N. Whitlock Avenue Crawfordsville, IN 47933 T:(765)362-8912 F:(765)362-6901
Membership Information Form
Contact Information
First Name:    Middle Name:    Last Name:
Name of Person Member Lives With: Home Phone:
Emergency Contact (name):     Emergency Contact (phone number with ext.):
Address:     City:     State:     Zip:
Email Address:
Demographic Information
Gender: Male Female    Birthdate: (mo/da/yr) eg.:02/03/04   Age:			Ethnicity- Select One: African American Puerto Rican Cuban South American Caucasian Multi-Racial Latino Hispanic Asian American Pacific Islander Native American
Family Totals:    Sisters:    Brothers:     Household:    Member Lives with- Select One: Both Parents Mother Father Aunt/Uncle Guardian Grandparent Other
Member before? yes no   if yes how long? (number of years?)   Census Tract:
Name of Unit:
Parent/Guardian Information
Father's First Name: Father's Last Name: Father's Work Phone & Ext:
Father's Employer: Father's Occupation:
Mother's First Name: Mother's Last Name: Mother's Work Phone & Ext:
Mother's Employer: Mother's Occupation:
Guardian's First Name: Guardian's Last Name: Guardian's Work Phone & Ext:
Guardian's Employer: Guardian's Occupation:
Medical/Emergency Information
Medical Problems/Allergies:
Medications:
Physician: Physician Phone:
Preferred Hospital or Clinic: Hospital Phone:
Insurance Company: Insurance Policy Number:
Can Member Swim? yes no
Pick Up Information
Names of two Persons Authorized to pick up Member:
1)First Name: 1)Last Name:
2)First Name: 2)Last Name:
Persons Not Authorized: Authorized Password:
Notes
Participation in other Youth Programs: Hobbies:
Nickname: Mother's Maiden Name:
Confidential Information
Member's Social Security Number: Medicaid Number:
Annual Family Income: $9,000 or below $9,001-$12,000 $12,001-$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 $42,001-and above Select all that apply: SSDI SSI TANF Day Care Voucher Food Stamps General Assistance School Lunch Vet. Compensation
Child's Labor Force Status: Child's Family Setting: One Parent Family Two Parent Family Other
Disability: Child's Household Type:
I have read the completed application, understand the rules of the B&GC of Montgomery County and request that my son/daughter be admitted into membership. I have explained the rules to my son/daughter and agree that the B&GC of Montgomery County will not be responsible for any accident to the boy/girl while on the B&GC of Montgomery County premises or while engaged in any of its activities away from the B&GC property or facilities. I give my consent for photographs, in which my son/daughter may appear, to be used in any way the Club may care to use them.
Parent or Guardian Signature: Date:
Questions? Call 765-362-8912