MEMBERSHIP APPLICATION
AGES 6-18

A "renewal" form must be filled
out annually

 

Please print and complete an application for each child and mail it with a check or money order to:
Boys and Girls Club of Marshfield
P.O. Box 311, Library Plaza, Marshfield, MA 02050.
The cost for membership is $50.00 per child, up to $100.00 per family.

Click here for PDF printable version of the membership application.

Name of Child: ___________________________________________________________________
Address: ________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
Telephone#: (___)______________________________ E-mail: (parent) _________________________________
Gender: Male (___) Female (___) Date of Birth: _____/_____/_____
Ethnicity (optional): African-American(__) Asian(__) Caucasian(__) Hispanic(__) Multi-Racial(__) Native American(__)

Other(__)_______________________
School Name:______________________________________________________ Grade: _____________
GENERAL INFORMATION (Please Print)
Mother/Guardian Name: __________________________________________________________________________
Work # : (___)______________________________ Cell Phone # : (___)______________________________
Father/Guardian Name: __________________________________________________________________________
Work # : (___)______________________________ Cell Phone # : (___)______________________________
Applicant Lives with (please check all that apply):
Both Parents(__) Mother(__) Father(__) Aunt/Uncle(__) Sister/Brother(__) Grand Parent(__) Guardian(__) Other(__)_________________
Does your child qualify for the National School Lunch Program? No(__) Reduced Price(__) Free(__)
(This information is collected for obtaining grants only)
MEDICAL INFORMATION (for reference in the event of an emergency)
Asthma: No(__) Yes(__) Allergies: No(__) Yes(__) please specify:____________________
Phsyical Restrictions: No(__) Yes(__) please specify:_____________________________________________________________________
Other Issues: _____________________________________________________________________________________________________
Doctor: _______________________________________________ Clinic: ____________________________________________
Telephone#: ___________________________________________ Health Insurance : __________________________________
The mission of BGCM is to help boys and girls develop the qualities needed to become responsible citizens and leaders. The achieve this, we offer a variety of program activities and support services designed to assist in the educational, emotional, physical and social development of 6 to 18 year olds, without regard to social, racial, ethnic or religious background.
EMERGENCY CONTACTS (specify 2 people we can contact if there is no answer at your home/work) ONE MUST BE LOCAL
1. Name: ________________________________________________ 2. Name: ____________________________________________
Telephone#: _____________________________________________ Telephone#: _________________________________________
Cell Phone#: _____________________________________________ Cell Phone#: _________________________________________
Parents Please Read
LIABILITY CLAUSE
I hereby indemnify and hold harmless the Marshfield Boys And Girls Club, Inc. (the “Club”) and its employees, agents, representatives and volunteers from any claims, damages, actions, causes of action arising from or resulting from any bodily injuries, the effects thereof, or losses and damages arising there from, incurred or suffered by my child while in the Club facility, engaged in any Club sponsored activity, or arising from the use of the Club’s open door policy, unless such loss or injury results directly from the gross negligence or willful act of any of the Club’s employees acting within the scope of their employment or any of the Club’s agents, representatives and volunteers.

PHOTOGRAPHY RELEASE
I acknowledge that photographs may be taken of my child or children while they are either in the Club facility or engaged in Club sponsored activities in other locations and hereby consent to the use of such photographs by the Club in written material and press releases.

DROP IN POLICY
The Club maintains an open door policy at its facility in Library Plaza, Marshfield (the “Facility”). Members are supervised in the Facility for their own safety. The open door policy permits members to enter and leave the Facility at any time, and as many times, as they desire and no Club employee, agent, representative or volunteer shall be responsible for any member’s decision to leave, nor shall they be responsible for ensuring a member stays in the Facility. Decisions related to how any member uses the open door policy are solely the responsibility of the child and his or her parent or guardian, and no employee, agent, representative of volunteer of the Club is responsible for enforcing those family decisions. Please be sure this open door policy is appropriate for your child/children.

MEDICAL EMERGENCY CONTACT
In the event of injury, or should emergency care be required and I cannot be reached, I authorize staff from Boys &
Girls Clubs of Marshfield to sign for emergency medical attention for my child.
The completed application is factual and completed to the best of my ability. I understand that participation is contingent upon acknowledging receipt of BGCM’s posted rules and a commitment to attend an orientation session within 30 days of enrollment. 6 and 7 year old members and parents are required to attend an orientation session prior to participation. A birth certificate is required for all 6 & 7 year olds.
________________________________________________________ _ _ / _ _ / _ _
(signature of parent/guardian) (date)

Parents/Guardians - We need your help! (Please check all that apply)

Volunteer for special events: ______________________________________( Haunted House, Golf Tournament, Administrative, etc.)
Donate auction items: ___________________________________________(Gift Certificates, Services, Products, Sports Items, etc.)
Volunteer at the club: ______________________________________________________(Sports, Arts & Crafts, Homework Help, etc.)

The Boys and Girls Club of Marshfield is a privately funded organization and depends
on the generosity of individuals and corporations.
OFFICE USE ONLY
Membership # _______________

 Membership Date:____/_____/____
Membership Fee: _______________

  Date Fee Rec'd:____/_____/____
New(___) Renewal(___) Reinstated(___)
 
Name of staff entering data:___________________________________________

 

CONFIDENTIAL INFORMATION—OPTIONAL to fill out one form per family

All information provided on this form is anonymous and confidential—please do not include
your name, or the name of your child/children, on this form.

We need the following information in order to apply for funding from government sources and
charitable agencies. This funding is used to provide the programs and services available at the
Clubhouses at minimum cost to you. Thank you for your time and cooperation.
   
How many children do you have enrolled at the club? ____________________________________
Housing: Rent(___) Own(___) Public Housing(___) Other(___)____________________________
Household Size: Children (under 18) _____________ Adults: _____________
Annual Household Income:
$13,000 or below(___) $17,000 or below(___) $17,000 - $25,000(___)

$25,000 - $37,000(___) $37,501 - $42,000(___) $42,000 and above(___)
Family Financial Support (check all that apply):  
Temporary Assistance for Needy Families (TANF) (___)

 Social Security Disability Insurance (SSDI) (___)
Supplemental Security Income (SSI) (___)

 Day Care Voucher (___)
Food Stamps (___)

 Veterans Compensation (___)
General Assistance (___)

 School Lunch Program (___)
Thank you for your consideration in Filling out this information.

 

Membership

Membership has an annual fee of $50.00 per year. ($100.00 max for families)

Members must be 6yrs old to join. Birth Certificate required before the child may attend.

Membership ages are 6-18 years.

All members will be required to attend a membership orientation within 30 days of joining. Orientation will be coordinated by a staff member. Parents MUST attend the orientation.

New Hours

MWF:
3-6 pm ages 6 & up
6-7 pm ages 10 & up
Thurs:
1-5pm ages 6 & up
5-7 ages 10 & up

If you have questions regarding membership please contact Kathleen Newcomb:
KathleenN@marshfieldboysandgirlsclub.com

Please see our calendar for daily events!!