Membership Form – Boys and Girls Club Decatur

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859 North Jasper Street Decatur, IL 62521
Info@decaturilbgc.com

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859 North Jasper Street Decatur, IL 62521
info@decaturilbgc.com

Programs
News
About
Get Involved
Contact Us

Donate Join the Club

Membership Form

GREAT FUTURES START HERE.

IF YOU'RE FILLING OUT THIS FORM ON BEHALF A CHILD, PLEASE INSERT THE CHILD'S INFORMATION IN THE FORM!

General

How many members will you be filling out information for?

Member #1

Member Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Ethnicity(Required)

School(Required)

Grade(Required)

Teacher(Required)

Bus Number(Required)

Member #2

Member Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Ethnicity(Required)

School(Required)

Grade(Required)

Teacher(Required)

Bus Number(Required)

Member #3

Member Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Ethnicity(Required)

School(Required)

Grade(Required)

Teacher(Required)

Bus Number(Required)

Member #4

Member Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Ethnicity(Required)

School(Required)

Grade(Required)

Teacher(Required)

Bus Number(Required)

Member #5

Member Name(Required)

First Last

Gender(Required)

Date of Birth(Required)

MM slash DD slash YYYY

Age(Required)

Ethnicity(Required)

School(Required)

Grade(Required)

Teacher(Required)

Bus Number(Required)

Contact Information

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Email(Required)

Phone(Required)

Military Status(Required)

Status(Required)

Branch(Required)

Department of Defense ID Number(Required)

Currently Deployed(Required)

Member Details

Foster Care(Required)

School Lunch(Required)

Food Allergies (Select All That Apply)(Required)

Peanuts

Soy

Eggs

Tree Nuts

Gluten

Dairy/Lactose

Seafood/Shellfish

Other

None

Other Food Allergies

Environmental Allergies (Select All That Apply)(Required)

Bee Stings

Dust

Grass

Pollen

Mold

Other

None

Other Environmental Allergies

Medicine Allergies (Select All That Apply)(Required)

Penicillin

Amoxicillin

Aspirin

Other

None

Other Medicine Allergies

Other Allergies (Select All That Apply)(Required)

Latex

Lotions

Perfumes/Colognes

Other

None

Other Allergies

DPS61 ID # (Member #1)(Required)

DPS61 ID # (Member #2)(Required)

DPS61 ID # (Member #3)(Required)

DPS61 ID # (Member #4)(Required)

DPS61 ID # (Member #5)(Required)

Medical Information

Diagnosed Medical Conditions (Select All That Apply)(Required)

Asthma

ADD/ADHD

Diabetes

Autism

Hearing Impairment

Seizures

Anxiety/Depression

Visual Impairment

Oppositional Defiance Disorder

None

Other Diagnosed Medical Conditions

Does the member use an inhaler?(Required)

Does the member use insulin?(Required)

Does the member use an EpiPen?(Required)

Does the member self-administer medication?(Required)

Does the member receive additional support in the school/community?(Required)

Individualized Education Plan (IEP)

504 (accommodation)

Speech Coach

Meets with school or private counselor

Other

No Additional Support

Other Support In The School/Community

Insurance Information

Insurance Carrier(Required)

Group Number(Required)

Member Policy Number(Required)

Authorized Contacts

Authorized Contact 1(Required)

First Last

Authorized Contact 2

First Last

Email(Required)

Mobile Phone(Required)

Email

Phone

Work Phone

Emergency Contact(Required)

Work Phone

Emergency Contact

Relationship(Required)

Casework

Child

Grandchild

Grandparent

Neighbor

Parent

Stepdad

Stepmom

Other Relative

Other

Relationship

Casework

Child

Grandchild

Grandparent

Neighbor

Parent

Stepdad

Stepmom

Other Relative

Other

Non-Authorized Contacts

Please list any individuals that are restricted from picking up the member.

Non-Authorized Contact 1

First Last

Non-Authorized Contact 1

First Last

Phone

Phone

Relationship

Casework

Child

Grandchild

Grandparent

Neighbor

Parent

Stepdad

Stepmom

Other Relative

Other

Relationship

Casework

Child

Grandchild

Grandparent

Neighbor

Parent

Stepdad

Stepmom

Other Relative

Other

Start Date

MM slash DD slash YYYY

Start Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

End Date

MM slash DD slash YYYY

Household Support

Number of adults in the household(Required)

Number of children in the household(Required)

Household Composition(Required)

Single Adult Household

Two + Adult Household

Self (emancipated / 18)

Who are the adults living the household? (Check all that apply)(Required)

Mother

Father

Parents

Step Father

Step Mother

Grandparent(s)

Foster Parent(s)

Joint Custody

Legal Guardian(s)

Sibling(s)

Uncle

Aunt

Other Relative(s)

Other Adult(s)

Assistance Programs(Required)

Childcare Assistance

Food Stamps/SNAP

Medicaid

Medicare

Social Security

SSI (Social Security Income)

SSDI (Social Security Disability Income)

WIC (Women, Infants, and Children)

TANF (Temporary Assistance for Needy Families)

Veteran's Compensations

Housing Assistance

Other (please explain)

Choose Not to Answer

None

Housing Type(Required)

Housing Income Range(Required)

Other Assistance Programs

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We extend our sincere appreciation to our sponsors for their invaluable contributions.

The Boys & Girls Blub of Decatur is one of many clubs across the U.S. making a tremendous impact in the lives of our youth.

859 North Jasper Street Decatur, IL 62521
info@decaturilbgc.com
(217) 422-9605

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Fall Hours: Monday - Friday, 2:30PM-7:00PM

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