Parent / Guardian InformationParent / Guardian Name* First Last Gender* Female Male Address Address Type of Address Actions Edit Delete There are no Addresses. Add Address Maximum number of addresses reached. Phone Phone Number Type of Phone Number Actions Edit Delete There are no Phone Numbers. Add Phone Number Maximum number of phone numbers reached. Email Email Address Type of Email Actions Edit Delete There are no Email Addresses. Add Email Address Maximum number of email addresses reached. Family Size*(Number living in household)Please enter a number greater than or equal to 2.Family Income*$0 - 5,000$5,001 - 12,000$12,001 - 22,000$22,001 - 32,000$32,001 - 40,000$40,000 - aboveEmployer* Additional Adult / GuardianYou can add an additional adult - a guardian, spouse, etc. I would like to add another adult Spouse / Additional AdultParent / Guardian Name* First Last Gender* Female Male Address Address Type of Address Actions Edit Delete There are no Addresses. Add Address Maximum number of addresses reached. Phone Phone Number Type of Phone Number Actions Edit Delete There are no Phone Numbers. Add Phone Number Maximum number of phone numbers reached. Email Email Address Type of Email Actions Edit Delete There are no Email Addresses. Add Email Address Maximum number of email addresses reached. Member InformationMember(s) Child Name Select Membership Periods Date of Birth Current Grade Actions Edit Delete There are no Members. Add Member Maximum number of members reached. Parent / Guardian AgreementI have read the completed application, understand the rules of the Boys & Girls Club of White County and request that my son(s)/daughter(s) be admitted into membership. I have explained the rules to my son(s)/daughter(s) and agree that the Boys & Girls Club of White County will not be responsible for any accident to the member while on Club premises or while engaged in any of its activities away from the Club. I understand that this agreement applies to all members I am registering with this form.Parent / Guardian Signature*Membership Fee & PaymentWe encourage those who are able to give above and beyond to help support the program.Membership Fee* Price: $0.00 Additional Contribution Total Payment Type*I'd like to pay by... Credit Card Cash or Check Please bring cash or a check for the Fee Amount to the Club.You can make checks out to “Boys and Girls Club of White County LLC”.Credit Card*We accept: If you have trouble with the Card Details field, refresh the page and it should work again. All or most of the data you entered will remain, depending on your browser. Cardholder Name Card Details PhoneThis field is for validation purposes and should be left unchanged.
