Become a Member

Apache Junction - Membership

Name of Person Member Lives With: * First Last
Home Phone * - (###) - ### ####
Home Address *
Street Address

Address Line 2

City

State / Province / Region

Postal / Zip Code

Country
Email
Emergency Contact if Parent/Guardian Cannot be Reached:
Contact Name * First Last
Contact Phone * - (###) - ### ####
Contact Alternate Phone * - (###) - ### ####
Contact Relationship *
Parent/Guardian Information
Father's Name First Last
Father's Phone - (###) - ### ####
Father's Employer
Father's Work Phone - (###) - ### ####
Mother's Name First Last
Mother's Phone - (###) - ### ####
Mother's Employer
Mother's Work Phone - (###) - ### ####
Guardian's Name First Last
Guardian's Phone - (###) - ### ####
Guardian's Employer
Guardian's Work Phone - (###) - ### ####
Annual Household Income *

This information is STRICTLY CONFIDENTIAL. It is necessary for our records and the funding the Boys & Girls Clubs of the East Valley receives. Your cooperation in providing this information is appreciated. Thank You.
Family Participation in Assistance Programs (Check All Programs that Apply) * SSDI SSI TANF/AFDC Day Care Vouchers Food Stamps General Assistance School Lunch Program Veterans Compensation None of the above
This information is STRICTLY CONFIDENTIAL. It is necessary for our records and the funding the Boys & Girls Clubs of the East Valley receives. Your cooperation in providing this information is appreciated. Thank You.
Member Information (Child)
Member's Name * First Last
Member's Birthdate * / MM / DD YYYY
Age *
Nickname
Family Setting
Household Description
Status *
Gender
Ethnicity
Name of School
Grade of Student
Number of Sisters & Step-Sisters
Number of Brothers & Step-Brothers
Total Number of Persons in Household
Member Lives With
Handicap
Medical Problems / Physical / Allergies and Behavioral concerns
List All Medications Your Child is Taking
Physician's Name First Last
Physician's Phone - (###) - ### ####
Preferred Hospital or Clinic
Hospital/Clinic's Phone - (###) - ### ####
Is Your Child Covered Under an Insurance Program?
Name of Insurance Company
Insurance Policy Number
How did you hear about us?
Would you like to be a member of the Branch Board?

Become a Member

Apache Junction - Membership

Apache Junction - Membership

Emergency Contact if Parent/Guardian Cannot be Reached:

Parent/Guardian Information

Member Information (Child)