Membership Application

Lunda Center

405 State Highway 54
Black River Falls, WI 54615
Email
(715) 284-4005
$15 Membership Fee/Year
$30 Household Membership Fee/Year

Chippewa Falls Center

650 Bridgewater Ave
Chippewa Falls, WI 54729
Email
(715) 726-2065
$15 Membership Fee/Year
$30 Household Membership Fee/Year

Lee & Mary Markquart Center

1005 Oxford Avenue
Eau Claire, WI 54703
Email
(715) 855-0081
$15 Membership Fee/Year
$30 Household Membership Fee/Year

Menomonie Center

River Heights Elementary School
615 24th Avenue West
Menomonie, WI 54751
Email
(715) 233-2540
$15 Membership Fee/Year
$30 Household Membership Fee/Year

Altoona Center

1903 Bartlett Ave
Altoona, WI 54720
Email
(715) 838-7358
$15 Membership Fee/Year
$30 Household Membership Fee/Year

Become a Member

Step 1 of 5

20%

Please contact your local Club to schedule your required New Member Orientation prior to attending.
All information in this application is kept confidential.

Which club are you attending?*

Black River Falls

Chippewa Falls

Eau Claire

Menomonie

Altoona

Member Information

Name:*

First Middle Last

Member Birth Date:*

Gender:*

Ethnicity:*

Caucasian

African American

American Indian

Asian-Asian Pacific

Hispanic-Latino

Multi-Ethnic

Other

Other:

Member Primary Address:*

Street Address City State / Province / Region ZIP / Postal Code

Member Email:*

School:*

Grade:*

Teacher:*

Would you like to receive a scholarship application?

Yes, please.

No, thank you.

Are you a Group Health member?*

By checking here, I agree to share my name with Group Health to have my membership paid for.

Yes

Eligible for Reduced/Free Lunch?*

Yes

TANF Eligible?*

Yes

Is your child receiving any special services at school?*

Yes

Which services?

Speech

English Language Learner

Title I

Cognitive disability

Learning disability

Emotional/behavioral disability

Other interventions

Other:

Has your child ever been retained (held back)?*

Yes

Have there been truancy issues?*

Yes

Specify:

What are your child's grades?*

Are you satisfied with your child's grades?*

Yes

What homework would you like to see your child work on during the after-school program?*

How did you hear about the Club?*

Friends

Family

School

Other

Other:

Head of Household Information

Name:*

First Last

Gender:*

Relationship:*

Parent

Grandparent

Guardian

Other

What is your relationship to the member?*

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone:*

Email:*

Place of Employment:*

Other Parent/Guardian Information

Name:*

First Last

Gender:*

Relationship:*

Parent

Grandparent

Guardian

Other

What is your relationship to the member?*

Address:*

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone:*

Email:*

Place of Employment:*

Please check all that apply:*

Call in case of emergency

Authorized to pick up member

NOT authorized to pick up member

This contact may also make any changes to the account as they see fit

Alternate Authorized Contact Information

Name:

First Last

Gender:

Phone:

Relationship to Member:

Please check all that apply:

Call in case of emergency

Authorized to pick up member

NOT authorized to pick up member

Income Information

Income information is confidential. In order for this application to be complete, income must be reported to Club for reporting purposes.

Family Size:*

Family Income:*

Military?*

Yes

Which branch?

Member lives in:*

Single adult household

Multiple adult household

Member lives with:*

Check all that apply.

Both Parents

Mother

Father

Grandparent(s)

Guardian(s)

Relative(s)

Foster Parent(s)

Medical Information

Physician:

Phone:

Preferred Hospital/Clinic:

Phone:

Does member have any of the following? Check all that apply:*

Anxiety

Asthma

Attention Deficit Hyperactivity Disorder

Autism

Bi-Polar

Bleeding disorder

Bone/joint condition

Cancer

Depression

Diabetes

Ear infections

Eating Disorders

Epilepsy/seizures/blackouts

Gastrointestinal/bowel dis-order

Headaches/migraines

Hearing disabilities

Heart disease

Hepatitis

Hernia

High/low blood pressure

Kidney disease

Mental/emotional problems

Other

None of the above

Other:

Is member taking any medication?*

Yes

Name of medication:

Prescribing Doctor:

Doctor's Phone:

Amount to be taken:

How is it taken:

Time(s) of day to be taken:

Reason for taking/special instructions:

Name of medication:

Prescribing Doctor:

Doctor's Phone:

Amount to be taken:

How is it taken:

Time(s) of day to be taken:

Reason for taking/special instructions:

Name of medication:

Prescribing Doctor:

Doctor's Phone:

Amount to be taken:

How is it taken:

Time(s) of day to be taken:

Reason for taking/special instructions:

Does your child have any allergies?*

Yes

Please explain and be as detailed as possible:

Are you child’s immunizations up to date?

Yes

Is your child receiving counseling?*

Yes

Is there any additional support you’re looking for from the Club?*

Yes

How can we support?

Social Development

Is there any family stress at this time?

Yes

Please specify:

Are there any drug/alcohol related concerns in the family?

Yes

Please specify:

Are there any legal issues, past or present, with the child or other family members that we need to be aware of?

Yes

Please specify:

Do you feel your child is being bullied or is bullying others at school?

Yes

If yes, what has been done about it?

Membership Release Form

Please read each statement and check that you agree and sign and date the bottom of this form.

Liability:*

I agree.

I understand that Boys & Girls Clubs of the Greater Chippewa Valley is not responsible or liable in any way in the event of harm or injury occurring to my child. It is agreed that I will hold Boys & Girls Clubs of the Greater Chippewa Valley harmless for the actions of my children or the action of other children that result in the harm of others or damage to property, including activities outside of the Club. I authorize the Boys & Girls Clubs of the Greater Chippewa Valley to seek medical attention for my child should the need arise.

Live-Safe / Text Message Applications:*

I agree.

I understand that it is my responsibility to download the LiveSafe app to my phone as part of the emergency preparedness of the Boys & Girls Club. OR I am unable to download the LiveSafe app, but will sign up for text messages from the Club.

Communicable Diseases:*

I agree.

I acknowledge the contagious nature of communicable diseases and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by communicable diseases by attending the Club and that such exposure or infection may result in personal injury, illness, permanent disability, or death.

Transportation:*

I agree.

I am giving permission for my child to be transported in the Boys & Girls Club van/ chartered school bus from school and/or to/from any field trips relating to program activities that are held during regular program hours.

Photos/Videos:*

I am giving consent for photographs, videos, and/or like materials, in which my child may appear, to be used in any promotional materials the Boys & Girls Clubs of the Greater Chippewa Valley may care to use them.

I agree

I disagree

Release of Academic Information:*

I am giving permission for the school my son/daughter attends to share attendance information, quarter and semester grades, suspension information, standardized test information, and any other information that relates to classroom performance, and behavior, with the staff of the Boys & Girls Club. This information will be used only by the staff in aggregated data reports and will not be used in any way that could identify an individual student.

I agree

I disagree

Computer Lab Use Policy:*

I agree.

I understand and will abide by the Computer Lab Use Policy of the Boys & Girls Clubs of the Greater Chippewa Valley as stated in the Great Futures Guide. If I commit any violation, I will respect the decision of the Boys & Girls Club staff as to the consequences of my actions.

Computer Lab Use Policy (cont.):*

I have read the Electronics Policy of the Boys & Girls Clubs as stated in the Great Futures Guide. I understand that this access is designed for educational and entertainment purposes and precautions have been taken to eliminate controversial material. I also recognize, however, that it is impossible for the Boys & Girls Club to restrict access to all controversial materials. I will not hold the Boys & Girls Club responsible for unintentional exposure to such material while on the internet. Further, I accept full responsibility for all intentional harm caused by my child to computer resources of the Boys & Girls Clubs of the Greater Chippewa Valley or any other affected parties.

As the parent/guardian, I give permission for my child to use the computer resources at the Boys & Girls Clubs of the Greater Chippewa Valley.

As the parent/guardian, I DO NOT GIVE PERMISSION for my child to use the computer resources at the Boys & Girls Clubs of the Greater Chippewa Valley.

Personal Technology Policy:*

I agree.

I have read and will abide by the Member Personal Technology/Phone Use Policy of the Boys & Girls Club of the Greater Chippewa Valley as stated in the Great Futures Guide. If I commit any violation, I will respect the decision of the Boys & Girls Club staff as to the consequences of my actions.

Authorization to Leave the Club:*

I understand that I must provide verbal or written consent for my child to leave the Boys & Girls Clubs of the Greater Chippewa Valley unescorted if I do not agree to the above statement. I understand that my child may not re-enter the Club after leaving. If my child has an appointment and I request he/she returns to the Club I will seek approval from Club staff.

My child has my permission to check him/herself out of the Club and leave unescorted.

As the parent/guardian, I DO NOT GIVE PERMISSION for my child to leave the Boys & Girls Club unescorted.

Mentoring Program:*

I give permission for my child to be considered for participation in additional mentoring provided through the Club. I understand that should my child be selected, additional documentation/waivers will be provided.

I agree

I disagree

I have read all of the above information and agree to the terms set forth by the Boys & Girls Clubs of the Greater Chippewa Valley.

MEMBER: I will try to be safe, legal, reasonable, respectful, and responsible while at the Club or participating in Club activities.

PARENT & MEMBER: I have read and agree to abide by all items in the Great Futures Guide. By signing below you verify all information given in this application is accurate to the best of your knowledge.

Member Signature:*

Date:*

MM slash DD slash YYYY

Parent/Guardian Signature:*

Date:*

MM slash DD slash YYYY

6 + 5 =*

CAPTCHA

Lunda Center

Chippewa Falls Center

Lee & Mary Markquart Center

Menomonie Center

Altoona Center

Become a Member

Member Information

Head of Household Information

Other Parent/Guardian Information

Alternate Authorized Contact Information

Income Information

Medical Information

Social Development

Membership Release Form

Quick Links

Members

Subscribe

Contact

Membership Application

Lunda Center

Chippewa Falls Center

Lee & Mary Markquart Center

Menomonie Center

Altoona Center

Become a Member

Member Information

Head of Household Information

Other Parent/Guardian Information

Alternate Authorized Contact Information

Income Information

Medical Information

Social Development

Membership Release Form

Find a Boys & Girls Club.

Footer

Quick Links

Members

Subscribe

Contact