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Programs
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Membership Application
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Membership Application
First Name
Middle Name
Last Name
Gender
Male
Female
Ethnicity
Date of Birth
Address
City
Zip Code
Phone
Cell Phone
Parent Email
Birth Certificate on File
Yes
No
Birth City
Birth State/Country
Member/Contacts Understood Signed Insurance Disclaimer and Permission Statement:
Yes
No
Member has permission to be used in public relations materials:
Yes
No
Member may participate in all the Centers activities in or adjacent to the Center's building:
Yes
No
Member Since
Religion
Eye Color
Hair Color
Height
Weight
Skin Color
Identifying Features
Center for Youth and Community Development Program(s) of Choice (Check if any)
Science Academy (HYLA)
Math Academy (HYLA) Triple Play/Healthy Habits
Image Makers
Music Makers
Power Hour/Homework Help
Reading for Success
Community Garden
Martial Arts
First Name
Middle Name
Last Name
Email
Work Phone
Cell Phone
Member lives with
Mom
Step Mom
Dad
Step Dad
Grandparent(s)
Foster Parent(s)
Annual Income Level
Number of People in Household
Number of People under 18
Is there a Member of the Household 65 years old or older:
Yes
No
Is there a Member of the Household Handicapped:
Yes
No
Current Head of Household:
Female
Male
Both
Current Single Parent:
Yes
No
School
GPA
Grade
Teacher/Counselor
Does Member like school?
Yes
No
Favorite Subject
Least Favorite Subject
Students Characteristics (Check if any)
Obedient
Aggressive
Strong Tempered
Team Player
Selfish
Sensitive
Cheerful
Alert
Bragger
Moody
Strong Willed
Easily Influenced
Doctor Name
Doctor Phone
Permission for Treatment by Doctor/Hospital
Yes
No
Medicaid
Yes
No
Does your family have health and/or accident insurance?
Yes
No
Insurance Carrier
Policy #
Group #
Date of Last Medical Exam
Serious Health Problems
Medications
Food Allergies
Date Medical Information Received
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