Membership

Online Membership

Membership Category * General Membership: for grades 1-8;$125.00 per family, per school year. Seasonal General Membership: Fall and Spring $75.00, Winter $100.00. Check here if your family is enrolled in the Kids Corp or Transportation Programs.
Please select what applies
Financial Aid Is Available:
Scholarship Request No child will be denied membership if they can not afford to pay. Those seeking Scholarship assistance should check the box, fill out the Scholarship Form, and provide needed information.
MEMBERSHIP STATUS
Please Check One * Renewal New Membership
Please select the one
I. CHILD INFORMATION
Child #1 First Name *
Child #1 Last Name *
Child #1 Date of Birth *
Child #1 School *
Child #1 Grade *
Child #1 Age *
Child # 1 Gender * Boy Girl
CHILD 2 IF NEEDED:
Child #2 First Name
Child #2 Last Name
Child #2 Date of Birth
Child #2 School
Child #2 Grade
Child #2 Age
Child #2 Gender Boy Girl
CHILD 3 IF NEEDED:
Child #3 First Name
Child #3 Last Name
Child #3 Date of Birth
Child #3 School
Child #3 Grade
Child #3 Age
Child #3 Gender Boy Girl
CHILD 4 IF NEEDED:
Child #4 First Name
Child #4 Last Name
Child #4 Date of Birth
Child #4 School
Child #4 Age
Child #4 Gender Boy Girl
II. FAMILY INFORMATION
Family Information Parent/Guardian #1 First Name *
Family Information Parent/Guardian #1 Last Name *
Family Information Parent/Guardian #1 Address
Family Information Parent/Guardian #1 City, State, Zip *
Family Information Parent/Guardian #1 Home Phone *
Family Information Parent/Guardian #1 Cell Phone *
Family Information Parent/Guardian #1 Email Address *
Family Information Parent/Guardian #1 Employer *
Family Information Parent/Guardian #1 Work Phone *
Family Information Parent/Guardian #1 Occupation *
2ND PARENT/GUARDIAN
Family Information Parent/Guardian #2 First Name
Family Information Parent/Guardian #2 Last Name
Family Information Parent/Guardian #2 Address ( If Different)
Family Information Parent/Guardian #2 City, State, Zip
Family Information Parent/Guardian #2 Home Phone
Family Information Parent/Guardian #2 Cell Phone
Family Information Parent/Guardian #2 Email Address
Family Information Parent/Guardian #2 Employer
Family Information Parent/Guardian #2 Work Phone
Family Information Parent/Guardian #2 Occupation
III. FAMILY INFORMATION
Race: * African American Asian Caucasian Hispanic Multi-Racial Native American
Income: * less than $ 9,999 $10,000 - $14,999 $15,000 - $24,999 $25,000 - $34,999 $35,000 - $44,999 $45,000 - $54,999 $55,000 - $64,999 Over $65,000
Single Parent Household: * Yes No
Number of people in household: *
IV. EMERGENCY CONTACTS
Emergency Contact #1 First Name *
Emergency Contact #1 Last Name *
Emergency Contact #1 Relationship to child *
Emergency Contact #1 Home Phone
Emergency Contact #1 Cell Phone
Emergency Contact #2 First Name
Emergency Contact #2 Last Name
Emergency Contact #2 Relationship to child
Emergency Contact #2 Home Phone
Emergency Contact #2 Cell Phone
V. MEDICAL INFORMATION

PLEASE LIST YOUR CHILD(ren)s HEALTH CARE INSURANCE PROVIDER
Health Insurance Provider *
Please list any Allergies, Medical, or Social conditions your child/children may have that may affect their participation in activities at the club. Make sure to include all prescribed medications taken by your child. *

PLEASE LIST ALL MEDICATIONS, MEDICAL , SOCIAL CONDITIONS AND RESTRICTIONS.
VI. PHOTO RELEASE
I give consent for photographs to be taken of my child(ren) to be used in displays, brochures, newsletters etc., exclusively for the John M. Barry Boys & Girls Club of Newton
* Yes No
VII. REPORT CARD RELEASE
I give consent for the Program Director to view my child™s report card to enable their participation in
reward and incentive programs and to provide data to gage the effectiveness of educational programs
offered at the John M. Barry Boys & Girls Club of Newton. All information is confidential.
* Yes No
VIII. SURVEY RELEASE
I give consent for my child(ren)to participate in member surveys as part of our impact assessment initiatives. The data is used to make improvements to programs and is vital to our efforts to secure
funding from outside sources. All responses are confidential.
* Yes No
DIGITIAL SIGNATURE

In order to conduct certain transactions with the John M. Barry Boys & Gilrs Club of Newton by electronic means, you, or your authorized representative, will be required to use an electronic signature when such signature is necessary. We will ask that you also agree to all terms and conditions presented in an Electronic Application. Please be aware that an electronic signature is as legally binding as a handwritten signature.

The Electronic Signatures Act (Public Law No: 106-229) went into effect on October 1, 2000 and gives electronic contracts the same weight as those executed on paper.
Digital Signature: I hereby give my permission for my child to join the John M. Barry Boys & Girls Club and to participate in all Club activities. I certify that my child is fit and capable of participating in activities without restriction unless noted above. I hereby, for myself, my child, my heirs, executors, and administrators waiver and release any and all rights and claims for damages I or my child may have against The John M. Barry Boys & Girls Club, its staff, and members of its Board of Directors, for any and all injuries suffered by during participation in Club-sponsored activities.

Please Type In Your Digital Signature Below : *
Please Select Today's Date * / MM / DD YYYY

Membership

Membership

Financial Aid Is Available:

MEMBERSHIP STATUS

I. CHILD INFORMATION

CHILD 2 IF NEEDED:

CHILD 3 IF NEEDED:

CHILD 4 IF NEEDED:

II. FAMILY INFORMATION

2ND PARENT/GUARDIAN

III. FAMILY INFORMATION

IV. EMERGENCY CONTACTS

V. MEDICAL INFORMATION

VI. PHOTO RELEASE

VII. REPORT CARD RELEASE

VIII. SURVEY RELEASE

DIGITIAL SIGNATURE