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Club Application Form

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Member Information:



Site Location or Program Name:*

Space is limited Please contact your local Club for further details.

This form must be filled by parents only

The Boy & Girls Club of Greater Holyoke, Inc.
70 Nick Cosmos Way.
Holyoke, MA 01041
Phone: 413-534-7366
Fax: 413-534-7369



Toepfert Unit
22 North. Summer St.
Community Room
Holyoke, MA 01040
Phone: 413-534-1681

Lyman Unit
18 1/2 Oliver St.
Holyoke, MA 01040
Phone: 413-536-7717



Churchill Unit
334 Elm Street.
Holyoke, MA 01040
Phone: 413-533-4922

Beaudoin Unit
15 Barrett Dr.
Holyoke, MA 01040
Phone: 413-538-6713



Name:*
Middle Name:
Nickname:
Birth Date:*
Age:*
Sex:*
Ethnicity:*
Address:*
Phone:*
-

School Information:


Current School:*
Current grade:*
Current Teacher:
IEP Record Release:*
Free or Reduce Lunch:*
Preferred Activity:
High School Graduation Year:

Emergency contacts/Authorized to pick up child:
I give my consent to the Boys & Girls Club of Greater Holyoke Inc. to release my child to the following persons (other than parent/guardian)authorized to take my child from program or received child at the end of the day:

First Contact Name:*
First Contact Pickup/Emergency:*
First Contact Relationship:*
First Contact Phone:*
-
Second Contact Name:
Second Contact Pickup/Emergency:
Second Contact Relationship:
Second Contact Phone:
-
Third Contact Name:
Third Contact Pickup/Emergency:
Third Contact Relationship:
Third Contact Phone:
-

Medical Information:

Doctor Name*
Doctor Address:
Doctor Phone:
-
Child’s Insurance Carrier:
Policy #:
Group #:
Serious Health Problems:*
Medication needed:*
If yes, explain:
Comments:
Permission for treatment by doctor / hospital:

Household:

Member lives with:*
Current Housing Area:
Number in Household:*
Number Under 18:*
Annual Income Level:*
Member of Household older than 65:*
Member of Household Handicapped:*
Single Parent:*
Current Head of Household:*
Is Parent/Guardian active in Military?:
If yes, which Branch:

Physical:

Eye Color:
Hair Color:
Skin Color:
T Shirt Size:

Parent/Guardian Information:

Parent Name:*
Parent Relationship:*
Parent Address:*
Parent Home Phone:*
-
Employment:
Occupation:
Parent Work Address:
Parent Work Phone:
-
Extension Number:
Parent Cell Phone:
-
Parent E-Mail:*

Transportation Policy:
The Boys and Girls Club of Greater Holyoke, Inc. does not provide transportation to or from school to the Boys and Girls Club. However the parents of the School Age Childcare Program have the option to contact the Holyoke Public Schools for transportation from School to the Boys and Girls Club.

Program Release Consent Form: The Boys and Girls Club’s School Age Child Care Program offers swimming lessons, crafts, and other activities on a scheduled basis in conjunction with the Club’s regular activities. To ensure that the SACC participants are offered age and skill level appropriate placements these activities, we will, with your permission, sign your child out of the SACC program and into the specific classes. At the completion of the class, your child will return to the SACC program. At all times your child will be under the supervision of Boys and Girls Club staff, however, the swim lessons, crafts, and gymnasium activities are not EEC licensed.
I hereby give my consent to the SACC program to sign my child out to the appropriate Boys and Girls Club programs: *
I hereby authorize the Director or his/her representative to act on my behalf in case my child/ward is a victim of a major accident, injury, or illness wherein immediate medical or surgical care is needed, providing a member of the Boys and Girls Club Staff shall make diligent effort to FIRST notify me of the situation and obtain my preferences. I hereby authorize duly licensed medical personnel to take such action as his/her judgement dictates: I further agree that neither Boys and Girls Club of America, nor any person associated with any Boys and Girls Club has any responsibility of any kind to me or my child/ward from any claims arising from any accident, injury or illness that my child/ward may suffer as the result of any such health care or medical treatment:*
My child may participate in all Boys & Girls Club activities in or adjacent to the club building: *
My child has permission to be used in public relation materials:*
I give my permission to the Boys & Girls Club of Holyoke staff to talk to my child’s teachers about his/her performance in school:*
BOYS & GIRLS CLUB RULES:
We encourage positive attitudes, education, good sportsmanship, and friendship. As A Member You Are Expected To:
  • Be Respectful- of other members, staff, and their property.
  • Be Kind- bullying will not be tolerated. Say only good things about others.
  • Use appropriate language- No swearing.
  • Take care of your Boys & Girls Club- clean up. Destroying property will result in a suspension.
  • Play fair and be honest- No fighting or stealing. Resolve disagreements in a positive way.
  • Be a good sport- share games, applaud efforts of others.
If you break the rules, here is what will happen:
  • Strike One- We will explain what you have done wrong, warning.
  • Strike two- You will be removed from current activity, time out.
  • Strike three- Suspension. Dress appropriately at all times.

 Remove hats before entering the building.

I have read the completed application and this form, understand the rules of the Boys & Girls Club and request that my child be admitted into membership.*
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