Auburn/Lewiston Clubhouse Member Registration

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Auburn/Lewiston Registration Form

Auburn Clubhouse

Auburn Member Registration

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COVID-19 Update

Auburn Lewiston Membership Application

IMPORTANT

IMPORTANT: Click the 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.

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Member Info

MEMBER INFORMATION

Member First Name:

Member Last 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:

Primary Language at Home

Member lives primarily with: (check all that apply)

Mother

Father

Grandparent

Other Relative

Other Guardian

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

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.)

ADD/ADHD

Asthma

Diabetes

Cerebral Palsy/Other Motor Condition

Epilepsy/Seizure Disorder

Emotional/Behavioral Disorder

NONE

Other Medical Conditions:

Does the Member have allergies or dietary restrictions?

Please check all that apply:

Bee Stings

Beef

Pork

Fish/Shellfish

Milk/Dairy

Peanuts

Penicillin

Tree Nuts

Wheat/Gluten

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 2023:

School Cooperation Release

SCHOOL COOPERATION RELEASE

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.

Yes

No

Parent/Guardian Info

PARENT/GUARDIAN INFORMATION

Parent/Guardian First Name:

Parent/Guardian Last Name:

Relationship to Member:

Mother

Father

Step-Mother

Step-Father

Aunt

Uncle

Sister

Brother

Cousin

Grandparent

Foster Parent

Other

Parent/Guardian Address

Parent/Guardian Phone

Parent/Guardian Email

Preferred Method of Contact:

Phone Call

Text Message

Email

Parent/Guardian Name

Relationship to Member

Mother

Father

Step-Mother

Step-Father

Aunt

Uncle

Sister

Brother

Cousin

Grandparent

Foster Parent

Other

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 First Name (if parent/guardian cannot be reached):

Emergency Contact Last Name

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):

$0-$30,150

$30,151-$40,600

$40,601-$51,050

$51,051-$61,500

$61,501-$71,950

$71,951-$82,400

$82,401-$92,850

$92,851-$103,300

$103,301-$113,750

$113,751-$124,200

$124,201 & Above

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.

Yes

No

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.

Thank you for registering. You will hear from us with more details by August 30th.

Oops, there was an error sending your message.

Please try again or contact Auburn Lewiston Unit Director Gary Violette at gviolette@bgcmaine.org

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Contact your neighborhood club

Auburn/Lewiston Clubhouse (Auburn)

Portland Clubhouse

South Portland Clubhouse

Main Offices

277 Cumberland Avenue

PO Box 7830, Portland, ME 04112

info@bgcmaine.org

T: (207) 874-1069

F: (207) 874-1074

Charity Navigator Four Star Award for BGCSM

United Way Member Agency

MEMBER AGENCY

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