Teen Center Membership Registration

BOYS & GIRLS CLUB OF FREDERICK COUNTY

Home
About Us
Our Curriculum
- Resources
Programs
- After School Program
- Summer Camp
Events
- Mural Sponsorship
- Battle of the Bands
Parent Portal
- Make Payment
- Safety
Get Involved
Previous Events

BGCFC Teen Center Membership Application

Member Information

* Indicates required field

First Name *

Middle Name *

Last Name *

Nick Name *

Date of Birth (XX/YYYY) *

School *

Grade *

Gender: *

Male Female

Ethnicity *

African American Asian Caucasian Hispanic Multiracial Native American Other (Answer next Ethnicity Question, please!

If Other: *

Family Type: *

Non-Traditional 1 Parent 2 Parent

Medical Problems or Allergies: *

Medications (list): *

Parent / Guardian Information

First Name *

Last Name *

Gender *

Male Female

Home Phone *

Cell Phone *

Work Phone *

Address *

City *

State *

Zip Code *

Email *

Employer *

Job Title *

Other Parent

First Name *

Last Name *

Gender *

Male Female

Home Phone *

Cell Phone *

Work Phone *

Home Address *

City *

State *

Zip Code *

Email *

Employer *

Job Title *

Annual Family Income ( Will NOT be shared!) *

$0 - $23,500 $23,551 - $74,500 $74,501 - And Above

Emergency Contact & Authorized Pick-Up

First Name *

Last Name *

Cell Phone *

Home Phone *

Relationship to Child *

First Name *

Last Name *

Cell Phone *

Home Phone *

Relationship to Child *

I give Boys & Girls Club of Frederick County permission to view my child's report card for general outcomes tracking. At no time will BGCFC ever post or share this information. *

Yes No

Everything listed above is true to the best of my knowledge. I hereby approve of this application and give permission for my child to join Boys & Girls Club of Frederick County's Teen Center. I also approve of my child's participation in the Teen Center activities and assume that my child is in good physical health and will not hold the Club Staff, Board, or Volunteers responsible beyond their control. In the event that I cannot be reached in an emergency, I hereby give permission to the physician selected by BGCFC to hospitalize, to secure proper treatment for, and to order needed injection, sedationi, anesthesia, X-rays, or surgery for my child as named above. I also grant BGCFC and its legal representatives and assign the irrevocable and unrestricted right to use and publish pictures of my child or in which my child may be included for editorial, trade, advertising, and any other purpose and in any matter and medium; to alter the same without restriction and to copyright the same. I hereby release BGCFC and its legal representatives and assigns from all claims and liability relating to said photographs. *

By submitting this Membership Application the Parent/Guardian is agreeing to the disclosure to the left. Please check yes or no *

Yes No

Please Consider Making a Donation to Support the Club

Please Consider Making a Donation to Support the Teen Center! Contact Shana Knight at 240-831-4330 with donation questions *

$25.00 $50.00 $100.00 Other

Submit

About Us
Parent Portal
Get Involved
Donate
Contact Us

Boys & Girls Club of Frederick County is a
501(c)(3) charitable organization.
Our tax ID number is 26-3424855.

413 Burck Street | Frederick, MD 21701 | 240-831-4330

Home
About Us
Our Curriculum
- Resources
Programs
- After School Program
- Summer Camp
Events
- Mural Sponsorship
- Battle of the Bands
Parent Portal
- Make Payment
- Safety
Get Involved
Previous Events