Last Name: First Name:
Address: Address Line 2:
Phone: Email:Address Line 2:

D/O/B Jan Feb Mar April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 M/F (select one) MALE FEMALE

Language: Race/Ethnicity:

YESNO Does your child have any medical or physical disabilities, or allergies which limit participation?

Parent/Guardian Address
Home Phone Cell Phone Work Phone

Parent/Guardian Address
Home Phone Cell Phone Work Phone

Person to contact if parent cannot be reached
RELATIONSHIP PHONE

I hereby give my permission for my child to join the Arlington Boys & Girls Club and participate in all Club
activities and acknowledge that my child is fit and capable or participating in these activities. I waive all rights for claims
that I may have against the Arlington Boys & Girls Club, Inc. its staff or Board of Directors for damages or injuries,
which may occur while my child participates in Club, sponsored activities. I understand that the Arlington Boys & Girls Club
does not carry personal injury or accident insurance.
Signature: Date:

Medical History

All parents are encouraged to complete this medical form. In the event of a medical emergency, the Boys &
Girls Club will provide this information to emergency services personnel caring for your child. The Boys & Girls Club
does not assume the responsibility of verifying or updating the information provided, you are urged to inform the Boys
& Girls Club of any changes to your physical condition.

Serious Diseases:

Physical Limitation:

Medications:

Hospitalization:

Physician: