Fillable Family/Adult Only Membership Application (City of Boston)

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Family/Adult Only Membership Application (City of Boston)

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For Office Use Only
Site: Date Received:
Staff Member Entering: ID: Fee Type:
Family/Adult Only
Membership Application
The mission of Boston Centers for Youth & Families is to enhance the quality of life for Boston residents by
partnering with community center councils, agencies, and businesses to support children, youth, individuals and
families through a wide range of comprehensive programs and services according to neighborhood needs.
HEAD OF HOUSEHOLD INFORMATION (Parent/Guardian) – Member 1
First Name: Last Name: Female Male
Home Address:
Street Apt. City/Neighborhood Zip Code
Home Phone: Cell Phone: Work Phone:
Email: Date of Birth:
Ethnicity (select all that apply): Asian Black Native American Native Hawaiian White
Are you of Hispanic or Latino origin? Yes No
To better serve the needs of our families and connect them to City services, we are requesting the following information.
Annual Household Income: Below $10,830 $10,831-14,570 $14,571-18,310 $18,311-22,050 $22,051-25,790
$25,791-29,530 $29,531-33,270 $33,271-37,010 $37,011-49,999 $50,000-74,999 $75,000+
Number of Family Members:
Housing: Rent Own Public Housing/Section 8 Shelter Other:
Assistance Programs (select all that apply): Day Care Voucher SNAP/Food Stamps General Assistance
Temporary Assistance for Needy Families (TANF) Medicaid SSDI SSI Veterans Compensation
Medical Information
Health Insurance Company:
Physician Name: Physician Phone Number:
Do you have any medical conditions or allergies? No Yes. If yes, please select type/s and describe below:
Allergies Asthma Physical Restrictions Medications Other:
Description:
Is there any additional information we should know about this you? No Yes
If yes, please list:
Emergency Contact Information
Please specify two people (other than a parent or guardian for youth) who can be contacted in case of emergency.
(These two contacts are authorized to pick-up youth family members from the Boston Centers for Youth & Families Community Center.)
Primary Contact Name: Relationship to member:
Home Address:
Street Apt. City/Neighborhood Zip Code
Home Phone: Work Phone: Cell Phone:
Secondary Contact Name: Relationship to member:
Home Address:
Street Apt. City/Neighborhood Zip Code
Home Phone: Work Phone: Cell Phone:
SPOUSE/PARTNER/SECOND PARENT/GUARDIAN INFORMATION – MEMBER 2
First Name: Last Name: Female Male
Home Address: Check here if same as Head of Household or
Street Apt. City/Neighborhood Zip Code
Home Phone: Check here if same as Head of Household or
Cell Phone: Work Phone:
Email: Date of Birth:
Ethnicity (select all that apply): Asian Black Native American Native Hawaiian White
Are you of Hispanic or Latino origin? Yes No
Medical Information
Health Insurance Company:
Physician Name: Physician Phone Number:
Do you have any medical conditions or allergies? No Yes. If yes, please select type/s and describe below:
Allergies Asthma Physical Restrictions Medications Other:
Description:
Is there any additional information we should know about this member? No Yes
If yes, please list:
Consent
I have read and understand the BCYF Code of Conduct and the BCYF Pool Rules and Regulations. I agree that I will act in accordance with the
BCYF Code of Conduct and abide by BCYF’s Pool Rules and Regulations.
The application is factual and complete to the best of my ability.
I hereby waive and release any and all rights, causes of action, and claims for damages I may have against the City of Boston, Boston Centers for
Youth & Families, and any and all other associated individuals or organizations, for any and all personal injuries or property damage resulting from
my participation in Boston Centers for Youth and Families Programs.
I, the undersigned parent or guardian of [______________], a minor, hereby consent to his/her Boston Centers for Youth and Families membership
and waive and release any and all rights, causes of action and claims for damages I may have against the City of Boston, Boston Centers for Youth
& Families, and any and all other associated individuals or organizations, arising out of any and all personal injuries or property damage which I may
now or hereafter have as the parent or guardian of said minor, and also all rights, causes of action, and claims which said minor has or may acquire
resulting from his/her participation in the program.
I give consent for me/my child to be administered first aid and to be treated by an emergency medical technician-paramedic, nurse or physician. Any
follow up medical attention may be given at a local hospital and transportation to a Boston hospital is authorized. I give my consent for photographs,
audiotapes, and video records of me/my child to be used by Boston Centers for Youth & Families for publicity purposes. I also agree to allow Boston
Centers for Youth & Families to use photographs, audiotapes, video records or other work produced by the member for publicity purposes.
I understand that transportation is not provided and it is my responsibility to arrange transportation to and from Boston Centers for Youth & Families
Community Centers.
Failure to comply with these rules and expectations can lead to termination of membership.
Signature of Member 1 Date
Signature of Member 2 Date
For Office Use Only
Site: Date Received:
Staff Member Entering: ID: Fee Type:
MEMBER 3 (CHILD)
First Name: Last Name:
Birth Date: Gender: Female Male
Ethnicity (select all that apply): Asian Black Native American Native Hawaiian White
Are you of Hispanic or Latino origin? Yes No
School: Grade: BPS ID#:
Type of School: Public Charter Private/Parochial Homeschool
Child lives with (select all that apply): Both Parents Mother Only Father Only Aunt/Uncle
Sister/Brother Step Parent Grandparent Foster Parent Guardian Other:
Home Address: Check here if same as Head of Household or
Home Phone: Check here if same as Head of Household or
Cell Phone: Work Phone: Email:
Medical Information
Health Insurance Company:
Physician Name: Physician Phone Number:
Do you have any medical conditions or allergies? No Yes. If yes, please select type/s and describe below:
Allergies Asthma Physical Restrictions Medications Other:
Description:
Is there any additional information we should know about this member? No Yes
If yes, please list:
MEMBER 4 (CHILD)
First Name: Last Name:
Birth Date: Gender: Female Male
Ethnicity (select all that apply): Asian Black Native American Native Hawaiian White
Are you of Hispanic or Latino origin? Yes No
School: Grade: BPS ID#:
Type of School: Public Charter Private/Parochial Homeschool
Child lives with (select all that apply): Both Parents Mother Only Father Only Aunt/Uncle
Sister/Brother Step Parent Grandparent Foster Parent Guardian Other:
Home Address: Check here if same as Head of Household or
Home Phone: Check here if same as Head of Household or
Cell Phone: Work Phone: Email:
Medical Information
Health Insurance Company:
Physician Name: Physician Phone Number:
Do you have any medical conditions or allergies? No Yes. If yes, please select type/s and describe below:
Allergies Asthma Physical Restrictions Medications Other:
Description:
Is there any additional information we should know about this member? No Yes
If yes, please list:
MEMBER 5 (CHILD)
First Name: Last Name:
Birth Date: Gender: Female Male
Ethnicity (select all that apply): Asian Black Native American Native Hawaiian White
Are you of Hispanic or Latino origin? Yes No
School: Grade: BPS ID#:
Type of School: Public Charter Private/Parochial Homeschool
Child lives with (select all that apply): Both Parents Mother Only Father Only Aunt/Uncle
Sister/Brother Step Parent Grandparent Foster Parent Guardian Other:
Home Address: Check here if same as Head of Household or
Home Phone: Check here if same as Head of Household or
Cell Phone: Work Phone: Email:
Medical Information
Health Insurance Company:
Physician Name: Physician Phone Number:
Do you have any medical conditions or allergies? No Yes. If yes, please select type/s and describe below:
Allergies Asthma Physical Restrictions Medications Other:
Description:
Is there any additional information we should know about this member? No Yes
If yes, please list:
Consent
I have read and understand the BCYF Code of Conduct and the BCYF Pool Rules and Regulations. I agree that I will act in accordance with the BCYF
Code of Conduct and abide by BCYF’s Pool Rules and Regulations.
The application is factual and complete to the best of my ability.
I hereby waive and release any and all rights, causes of action, and claims for damages I may have against the City of Boston, Boston Centers for Youth &
Families, and any and all other associated individuals or organizations, for any and all personal injuries or property damage resulting from my participation in
Boston Centers for Youth and Families Programs.
I, the undersigned parent or guardian of [
],
a minor, hereby consent to his/her Boston Centers for Youth and Families membership and waive and release any and all rights, causes of action and
claims for damages I may have against the City of Boston, Boston Centers for Youth & Families, and any and all other associated individuals or
organizations, arising out of any and all personal injuries or property damage which I may now or hereafter have as the parent or guardian of said minor, and
also all rights, causes of action, and claims which said minor has or may acquire resulting from his/her participation in the program.
I give consent for me/my child to be administered first aid and to be treated by an emergency medical technician-paramedic, nurse or physician. Any follow
up medical attention may be given at a local hospital and transportation to a Boston hospital is authorized. I give my consent for photographs, audiotapes,
and video records of me/my child to be used by Boston Centers for Youth & Families for publicity purposes. I also agree to allow Boston Centers for Youth
& Families to use photographs, audiotapes, video records or other work produced by the member for publicity purposes.
I understand that transportation is not provided and it is my responsibility to arrange transportation to and from Boston Centers for Youth & Families
Community Centers.
Failure to comply with these rules and expectations can lead to termination of membership.
Signature of Member 3 Date
Signature of Member 4 Date
Signature of Member 5 Date
Signature of Parent/Guardian (if member is under 18) Date
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FamilyAdult Only Membership Application (City of Boston)

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Completed 15 January 2021

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