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HOME
COVID-19 INFORMATION
Raise the Grade
ABOUT US
DONORS
FORMS
- 2021 Membership Form
- 2020-2021 Raise the Grade Registration
ANNUAL EVENTS
CONTACT US

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HOME
COVID-19 INFORMATION
Raise the Grade
ABOUT US
DONORS
FORMS
- 2021 Membership Form
- 2020-2021 Raise the Grade Registration
ANNUAL EVENTS
CONTACT US

2019-2020 Membership Form

2021 Membership Form

MEMBER INFORMATION

Member's Name *

First

Last

Birthdate (month/date/year) *

Physical Address (If different from mailing address.)

Address Line 1

City

State / Province / Region

Mailing Address *

Address Line 1

City

State / Province / Region

Postal Code

Gender *

Male
Female
Non-binary

School *

Health Card Number *

Siblings who are members:

Background Information (Voluntary): To support BGCB in tracking progress, statistics, and applying for funding, please check if any of the below categories apply to you.

First Nations
Metis
Francophone
ESL (English Second Language)
New Canadian
Immigrant

Country of Origin:

PARENT/GUARDIAN INFORMATION

Parent/Guardian #1 Information

Parent/Guardian #1 Name *

First

Last

Relation to Member *

Employer: *

Phone Number *

Cell Number *

Email *

Parent/Guardian #2 Information

Parent/Guardian #2 Name

First

Last

Relation to Member

Phone Number

Cell Number

Email

EMERGENCY CONTACTS

Please provide two emergency contacts OTHER THAN the parents/guardians listed above.

Emergency Contact #1 *

First

Last

Relation to Member *

Phone Number *

City of Residence *

Emergency Contact #2 *

First

Last

Relation to Member *

Phone Number *

City of Residence *

MEDICAL INFORMATION

Does your child have any special needs/requirements in the following areas? If yes, please explain further and indicate any diagnoses and medications that they are taking.

Select all those that apply. *

Allergies
Medical Condition(s)
Learning/Behavioral Needs
Other Considerations (Any additional information which may assist your child in positively participating in our programs.)
None of the above.

Allergies

Medical Condition(s)

Learning/Behavioral Needs

Other Considerations (Any additional information which may assist your child in positively participating in our programs.)

CUSTODY AND/OR COURT ORDER

Custody and/or Court Order *

Not Applicable
See Below

If a custody or court order exists, a copy of the order must be given to Boys & Girls Clubs of The Battlefords. The parent/guardian is responsible for providing accurate and up to date information concerning the legal guardianship of the child. Without a custody or court order on file, Boys & Girls Clubs of The Battlefords cannot deny access to the non-enrolling parent.

Please list anyone WHO IS NOT ALLOWED to pick up your child:

I have provided Boys & Girls Clubs of The Battlefords with legal documentation (custody or court order). Without this, BGCB cannot legally deny access to a non-enrolling parent.

Custody And/Or Court Order - NAME *

First

Last

Custody And/Or Court Order - DATE (month/day/year) *

PAYMENT

Our Annual Membership fee is $5 - this is due upon completing this membership form. With the membership fee, your child gains access to all programming offered at BGCb main site, Summer Drop-in Programs, as well as all Special Programs (ex: Hockey Program, Music Program, Soccer Program).

Payment Methods:

E-transfers can be sent to ac.bcgb@stnemyap. Please include the child's full name in the memo section. BGCB is set up for automatic deposit of e-transfers which means no password is required. When e-transfer is not available, the other forms of payment accepted at the office are: cash, debit or credit.

MEDIA CONSENT & RELEASE

Boys & Girls Clubs of The Battlefords has the right to use any artwork, photographs, video, and/or audio of my child while participating in club activities for the purpose of advertisement and promotional campaigns in the future. *

Yes, I agree.
No, I do not agree.

Media Consent & Release - NAME *

First

Last

Media Consent & Release - DATE (month/day/year) *

MEMBERSHIP CONTRACT

Parents/Guardians: Please review these guidelines/rules with your child.

If you want to become a member of Boys & Girls Clubs of The Battlefords (BGCB) and enjoy the privileges a member has you have to respect the staff, volunteers, and the other members. YOU MUST UNDERSTAND THAT BGCB IS A SAFE PLACE FOR ALL MEMBERS, AND IF YOU ACT IN A WAY THAT MAKES SOMEONE FEEL UNSAFE, YOU WILL BE ASKED TO LEAVE. You will follow the rules set by the staff. You also understand that if you do not abide by these rules, you may lose your privileges as a result and may not be able to return to BGCB in the future.

Parents/Guardians please read and agree to, by initialing beside, the following statements:

• I understand that my child is being asked to abide by the rules of BGCB. Should my child not abide by these rules, I agree to work with the staff of BGCB to help resolve the situation. *

• I understand that BGCB staff and volunteers will be supervising activities and programs during the hours of operation, and that it is my responsibility as parent/guardian to ensure my child’s safety before and after the hours of operation. *

• I understand that my child may leave the premises of BGCB at his/her own will, and that I will make every effort to communicate with my child when he/she is to leave BGCB. *

• I understand that should my child not be picked up prior to the closing hours of BGCB, the staff may be in contact with authorities such as the Battlefords RCMP and/or Social Services. *

• I agree that under no circumstances are BGCB staff members, volunteers or board members responsible for lost or stolen belongings. *

• I further understand that my child has my permission to attend programs offered through BGCB, some of which will require transportation to another location. *

• With full knowledge of the existence and nature of my legal right and in consideration for the opportunities provided to my child by BGCB, I waive my legal right against BGCB, its staff, volunteers, or Board of Directors for any injury or damage suffered during or by reason of practicing, participating or assisting in a club service, program, or experience. *

• I further authorize the application of emergency medical attention and undertake to be responsible for any hospitalization, medical, ambulance or other expenses. *

Membership Agreement - NAME *

First

Last

Membership Agreement - DATE & TIME *

Date

Time

This membership is valid from September 1st, 2020 to December 31st, 2021. Membership Fee is $5.00 per child. Membership Fee is non-refundable.

Name

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