MEMBER INFORMATION: Roosevelt Clubhouse 2010/2011 MEMBERSHIP APPLICATION Cabazon Central Hoffer Hemmerling Coombs Nicolet Anna Hause Brookside 3 Rings Ranch Sundance First Name:______________________ Last Name:__________________________ Nick Name:______________________ Gender: M F Ethnicity: Date of Birth:_________________ Age:______ Address:__________________________________________________________, ____________________, CA ____________ City Zip Telephone:_______________________________________________ _____________________________________________________________________________ School:_____________________________ Grade:_____ Teacher:_____________________ Y N Does child receive Free Lunch at school?Household Income: $0-18,000 $18,001-24,000 $24,001-26,000 $ ,000 $28,001-41,500 over $41,500 PARENT / GUARDIAN 1: Relationship:_______________ Employer:___________________ Name:_______________________________________ Telephone:_________________________ Home Cell Work EMERGENCY CONTACTS: Name:__________________________________ Telephone:______________________________ Home Cell Work Child lives with: Mother Father Both Other:__________________________ Please Circle Please Circle Please Circle MEDICAL: List Medication:_____________________________________ Medication: Y N Please Circle Please Circle List Food Allergy:_____________________________________ Food Allergy: Y N Contact us at: (951) fax: (951) PO Box 655, Beaumont, CA Please Circle African American Asian Caucasian Hispanic Native American Multi-Racial Other:____________________________ Relationship:_____________________________ Name:__________________________________ Telephone:______________________________ Home Cell Work Please Circle Relationship:_____________________________ ADDITIONAL NAMES AUTHORIZED TO PICK-UP CHILD: Name:_______________________________ Relationship:__________________________ Name:_______________________________ Relationship:__________________________ Name:_______________________________ Relationship:__________________________ Telephone:_________________________ Home Cell Work OFFICE USE ONLY: Date:_______________________ Staff Int:_______________________ Card #:_______________________ PARENT / GUARDIAN 2: Relationship:______________ Employer:____________________ Name:_______________________________________ Telephone:_________________________ Home Cell Work Please Circle Telephone:_________________________ Home Cell Work TO RECEIVE CLUB NEWS Circle All Programs That Apply:TANF SSDI SSI GENERAL ASSISTANCE FOOD STAMPS OTHER:_____________________________ Number of people in household:______ Tournament Hills

MEMBERSHIP APPLICATION PAGE 2 OF 2 PARENT / GUARDIAN CONSENT HEALTH HISTORY ALLERGIES DISEASES MEDICAL RELEASE This health history is correct so far as I know and the person herein described has permission to engage in all prescribed Club activities except as noted by the examining physician and me. I hereby give permission to the physician selected to hospitalize, secure proper treatment for, and to order injection and/or anesthesia and/or surgery for my child as named on this application. This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California. HOLD HARMLESS CLAUSE I further agree that the Boys & Girls Clubs of the San Gorgonio Pass, it’s Board of Directors, officers, staff and volunteers are hereby relieved of any and all liability, including but not limited to medical treatment, emergency transport or on-site assistance, in the event of accident or injury to the said minor. OPEN DOOR POLICY – DOES NOT APPLY TO SCHOOL SITES WHEN SCHOOL IS IN SESSION I understand the Boys & Girls Clubs of the San Gorgonio Pass has an “Open Door” policy that allows Club members to enter and leave the Clubhouse facilities as they choose. I understand that other adjacent areas outside the Clubhouse may not be supervised by the Boys & Girls Club staff, and because of the “Open Door” policy, my role as a parent determines where my child can play. Therefore, I agree that the Boys & Girls Club is not responsible for my child if they leave the Clubhouse premises. Also, I understand the Boys & Girls Clubs of the San Gorgonio Pass is not a licensed day care provider by its’ own choice. PUBLICIITY RELEASE I hereby consent to authorize the reproduction, publication and use the Boys & Girls Clubs of the San Gorgonio Pass and Boys & Girls Clubs of America, and their successors and assigns, for advertising, commercial, or any other purposes of any photograph picture or likeness of my child. CONSENT I have read and understand the above and hereby give my permission for my child to become a member of the Boys & Girls Clubs and to have my permission to participate in all the activities/programs offered by the Boys & Girls Clubs. I understand that my child must have good behavior and the Boys & Girls Club is a private organization and membership is a privilege and my be revoked at anytime. Additionally, I understand that the Boys & Girls Clubs is not responsible for the time or manner in which my child may arrive at or leave the Clubhouse, and that the Boys & Girls Club and its property are not responsible for personal injury or loss of property. Parent / Guardian signature: ____________________________________ Date: ___________________ Chicken Pox Measles German measles Mumps Asthma Ivy Poisoning Hay Fever Insect Stings Penicillin Other Drugs Frequent Ear Infections Heart Defect/Disease Convulsions Diabetes Bleeding/Clotting Disorders Contact us at: (951) fax: (951) PO Box 655, Beaumont, CA 92223