Al Lenzmeier West Side Membership Form

Member Information

Name *

First

Last

Gender *

Pronouns

She/Her/Hers
He/Him/His
They/Them
Other

Race/Ethnicity *

Birthdate *

MM/DD/YYYY

Member Phone Number *

Language Spoken at Home *

School *

School ID # *

Grade & HS Grad Year *

IEP
Special Education

School Lunch Program

Free
Reduced Cost

Allowed Transportation to/from Club *

Independent Walking
Adult Pick-Up
School Bus
Public Transit

Check all that apply.

Parent/Guardian (Emergency Contact)

Name *

First

Last

Relation to Member *

Gender

Guardian Phone Number *

Guardian Email Address *

Guardian 2 Name

First

Last

Guardian 2 Relation to Member

Guardian 2 Gender

Guardian 2 Phone Number

Guardian 2 Email Address

Household Information

Home Address *

Address Line 1

Address Line 2

City

State

Zip Code

No Permanent Housing:

Currently
Last 12 Months

Approx. Household Income *

Per Year

Household Setting *

Resources

Military Household

Service Branch and Status.

Member Medical Information

Insurance Type *

No Insurance
Medicare
Medicaid
Other Insurance

Insurance Company

Insurance Policy Number

Physician Name and Phone Number *

Preferred Hospital and Phone Number *

Medications

Please list any/all medications the member is taking.

Special Needs

Allergies/Dietary Restrictions

Emergency Contact Other Than Parent/Guardian

Name *

First

Last

Phone *

Relationship to Member *

Name

First

Last

Phone

Relationship to Member

TERMS OF AGREEMENT

I have explained the rules to my child and agree that the Club will not be responsible for any accident to my child while my child is on the Club premises or while engaged in any Club activities that take place away from the Club premises. I agree to release and hold the Club harmless from all claims relating to any such accident, and I agree to refrain from bringing suit or legal proceedings against the Club on account of any such accident.

I am aware that it is my responsibility to notify the Club of any changes to mine or my child's contact, medical, or other membership information including, but not limited to completing yearly updates to this form upon request by the Club.

My child and I understand the Club rules, and that my child needs a membership card to check in to the Club each day.

My child and I understand Club membership is a privilege and may be cancelled at any time for any reason.

I understand that membership is reserved for youth enrolled in Kindergarten through 12th grade. Members must be enrolled in school and be below the age of 18, verification of school enrollment and grade is required.

If my child's membership card is misplaced or destroyed, I agree to pay $1.00 to replace the card.

I understand the Club is not responsible for any of my child's lost, stolen, or damaged items. I will encourage my child to leave valuables at home.

I am aware of the Club's operating hours, and understand that I am solely responsible for my child's care outside these posted hours. Leaving my child alone before the Club opens, or picking up my child after the Club closes can result in loss of membership and notification of authorities.

I grant the Club the right to photograph and record my child and to use these as promotional materials. I release all right to copyrights title, property interest and/or any other interest of said reproductions, and I waive the right to inspect and approve any reproductions.

I understand that my child may be given surveys as part of program improvement efforts. All surveys are confidential and kept private.

I understand that my child will have access to the Internet at the Club.

I have completed this application, understand the rules and policies f the Club, and request that my child will be admitted into membership.

This organization participates in the Sprockets network, a youth program research collective, and other program improvement research initiatives which aim to improve the quality and availability of after-school and summer programs for youth and their families in the Twin Cities. Information about your child's participation in this activity will be used to help assess the quality and effectiveness of out of school time programs. Information about your child will be kept confidential and your child will never be identified in any evaluation or research reports. You have the right to review the Data Privacy Notice. If you do not want your child's date to be included in evaluation or research related to Sprockets, or other program improvement research initiatives, please tell our staff.

I authorize data sharing related to my child with the Sprockets,YMCA, Beacons Network, Boys & Girls Club of the Twin Cities, Richfield Public School and Minnesota Department of Education. Information about your child’s participation in this activity will be used to help assess the quality and effectiveness of out of school time programs. Information about your child will be kept confidential and your child will never be identified in any evaluation or research reports. You have the right to review the Data Privacy Notice. If you do not want your child’s data to be included in evaluation or research related to Sprockets, or other program improvement research initiatives, please tell our staff and sign the non-consent form. This will NOT affect your child’s participation in the program.

Parent/Guardian Signature *

Member Signature *

Today's Date *

Fill out this membership form and press submit. Then, wait to hear from your Club’s staff about orientation before dropping your child off at the Club. You will hear from your Club’s branch director soon!

Member Information

Parent/Guardian (Emergency Contact)

Household Information

Member Medical Information

Emergency Contact Other Than Parent/Guardian

TERMS OF AGREEMENT

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