Membership Application

If you are applying as a new member, be sure to register for Parent Orientation at the Club you are applying to. In order to register, please call or visit the Club your child will be attending.

PARENT ORIENTATIONS ARE MANDATORY FOR ALL CLUBS

Club members must be six years old and in first grade to join. KidsCare will take children as young as five and in kindergarten.

Member Contact Information


Mother/Guardian's Contact Information


Father/Guardian's Contact Information


Emergency Contact/Alternate Pick-Up


Member Demographic Information

Please Check One




Medical/Health History

Medications Being Taken (NOTE: MEDICATIONS WILL NOT BE DISPENSED BY STAFF)

Please provide name of medication, dosage, and specific times each dose is taken per day

Confidential: The following information is necessary for our records and the funding our organization receives. The answers you provide are completely confidential. Your cooperation in providing this information is both appreciated and necessary.


I, the parent/guardian of the minor child listed on this application, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Elkhart County, Boys & Girls Club of Goshen, Boys & Girls Club of Middlebury, Boys & Girls Club of Elkhart, Boys & Girls Club of Nappanee, KidsCare A Division of the Boys & Girls Clubs of Elkhart County, Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organizations such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury or death and any claim of damages resulting from use of facilities owned or controlled by the above organizations, or participation in activities of said organizations either at or away from the Club.
I give permission to the Boys & Girls Club to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any and all costs of medical attention and treatment.
I give my permission to the Boys & Girls Clubs of Elkhart County and to Elkhart Community Schools and/or Concord Community Schools and/or Wa-Nee Community Schools and/or Middlebury Community Schools and/or Goshen Community Schools to exchange information regarding the minor child listed on this application. The purpose of the exchange is to help both organizations do a better job of helping the student be successful in school, in the Boys & Girls Club, and in life. This release is valid for one year and may be revoked at any time by contacting Elkhart, Concord, Wa-Nee, Middlebury, and/or Goshen Community Schools or the Boys & Girls Club in writing.
I give my consent for photographs in which my child may appear to be used in any way the Boys & Girls Club may care to use them.
I understand that the Boys & Girls Club is not responsible for lost or stolen items.
I have read the completed application, answered all questions to the best of my ability and with all honesty to the best of my knowledge. I understand the rules of the Boys & Girls Club and request that my child be admitted into membership.

Please type your full name. Your electronic signature is legally binding. By signing you acknowledge and agree to the Liabilities Relase Waiver stated above.