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10/17/2017
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Registration Forms: Membership/Athletic Leagues/Programs and Summer Camp  

BOYS & GIRLS CLUB OF SPRINGVILLE

CLUB MEMBERSHIP / ATHLETIC LEAGUES/ PROGRAMS / SUMMER CAMP

REGISTERING FOR:  ___________________________________ 

First Name: _________________    Middle: ___________   Last: ________________________

Address:  ______________________________________________________________________           

City: ______________________   State: _________   Zip: ___________         

Telephone: ________________    Birth Date: ______________    Age: _____

Gender: ___Male   ___Female             Grade:  ______


Emergency Contact #:  _____________  Relationship:  _______________


Medical Information:

Doctor's Name: _______________________   Doctor's Phone #: _________________

Permission to contact Doctor/Hospital in case of Emergency:  ____Yes   ____No

Does your family have health and/or accident insurance?      ____Yes   ____No

  Insurance Carrier: _____________________________________________

  Policy #: _____________________   Group #: ______________________

 Serious Health Problems:   _____________________________________

Disclaimer:

I give my son/daughter, ________________________, permission to attend and participate in programs and/or leagues at the Boys & Girls Club of Springville.  I hereby release the Boys & Girls Club of Springville, its employees, associates, and contributors from liability from any injury, loss, or theft incurred by my child while participating in the program.  I hereby authorize medical examination and emergency treatment for my child by a qualified, licensed physician in the event of an accident.  My signature indicates that I agree to the above statement.                                                                                                                                                            

                      Parent/Guardian Signature: _____________________________

Please Mail Completed League Application to:

Boys & Girls Club of Springville, P.O. Box 128, Springville, NY 14141

 

 

 

 

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