Membership Information Form printable pdf download

Membership Information Form

Please Circle:

Pick-Up

Walker

Busser

MEMBERSHIP INFORMATION FORM

OFFICE USE ONLY:

Membership #

Date

Staff Signature

Shirt Size

Short Size

Boys & Girls Club of Gallup

Kid’s Trax ID #

Please Complete the Following Information (Please Print):

Member’s First Name

M.I

Last Name

Emergency Contact Person

Emergency Phone

Nickname

Birthdate

Gender (Circle One)

Age

Male or Female

Status (Please Circle One)

Ethnicity

White

Native American

Hispanic

New Member

Renewing Member

(Please

African American

Multi Racial

Asian

Number of Years Previous Member

Circle)

Other

Home Address

City

State

Zip Code

Home Phone Number

Name of School

Grade

Father’s First Name

Father’s Last Name

Father’s Occupation

Father’s Employer

Father’s Work Phone Number

Extension

Mother’s First Name

Mother’s Last Name

Mother’s Occupation

Mother’s Employer

Mother’s Work Phone Number

Extension

Guardian’s First Name

Guardian’s Last Name

Guardian’s Occupation

Guardian’s Employer

Guardian’s Work Phone Number

Extension

Member Lives With: (Circle One)

Both Parents

Mother

Father

Aunt/Uncle

Sister

Brother

Grandparents

Guardian

Membership Information Form

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