RMS Membership Form Thank you for your interest in joining a Boys & Girls Club of the Twin Cities! Please enable JavaScript in your browser to complete this form.Member InformationName *FirstLastGender *FemaleMaleNon-BinaryOtherPrefer Not to AnswerPronounsShe/Her/HersHe/Him/HisThey/ThemOtherRace/Ethnicity *Asian / Pacific IslanderWhite / CaucasianNative American / IndigenousHispanic / LatinoBlack / African AmericanMulti-RacialOtherPrefer Not to AnswerBirthdate *MM/DD/YYYYMember Phone Number *Language Spoken at Home *School *School ID # *Grade & HS Grad Year *IEPSpecial EducationSchool Lunch ProgramFreeReduced CostAllowed Transportation to/from Club *Independent WalkingAdult Pick-UpSchool BusPublic TransitCheck all that apply.Parent/Guardian (Emergency Contact)Name *FirstLastRelation to Member *GenderMaleFemaleNon BinaryOtherPrefer Not to AnswerGuardian Phone Number *Guardian Email Address *Guardian 2 NameFirstLastGuardian 2 Relation to MemberGuardian 2 GenderMaleFemaleNon BinaryOtherPrefer Not to AnswerGuardian 2 Phone NumberGuardian 2 Email AddressHousehold InformationHome Address *Address Line 1Address Line 2City--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeNo Permanent Housing:CurrentlyLast 12 MonthsApprox. Household Income *$10,000 or less$10,000-$14,999$15,000-$23,999$24,000-$34,999$35,000-$49,999$50,000 and overApprox. Household Income *Per YearHousehold Setting *Both ParentsSingle MotherSingle FatherOther FamilyFoster CareGroup HomeHomelessLiving Alone (single)OtherResourcesDaycare VoucherSupplemental Nutritional Assistance Program (SNAP)General AssistancePublic HousingTANFSSISSDIMedicaidMilitary HouseholdService Branch and Status.Member Medical InformationInsurance Type *No InsuranceMedicareMedicaidOther InsuranceInsurance CompanyInsurance Policy NumberPhysician Name and Phone Number *Preferred Hospital and Phone Number *MedicationsPlease list any/all medications the member is taking. Special NeedsAllergies/Dietary RestrictionsEmergency Contact Other Than Parent/GuardianName *FirstLastPhone *Relationship to Member *NameFirstLastPhoneRelationship to MemberTERMS OF AGREEMENTI 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 * Clear Signature Member Signature * Clear Signature Today's Date *Submit