MEMBER INFORMATION
First Name: Last Name: Female Male
Home Address: Date of Birth:
Street Apt. City/Neighborhood Zip Code
Home Phone: Cell Phone: Email:
Ethnicity (select all that apply): Asian Black Native American Native Hawaiian White Are you of Hispanic or Latino origin? Yes No
School: Grade:
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:
Medical Information
Health Insurance Company: Hospital Name:
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:
Parent/Guardian Contact Information (These two contacts are authorized to pick-up youth from Boston Centers for Youth & Families Community Centers.)
For Office Use Only
Date Received: Staff Member Entering: ID: Fee Type:
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 (BCYF), and any and all other associated individuals or organizations, for any and all personal injuries or property damage resulting from my participation in
BCYF Programs.
I, the undersigned parent or guardian of [______________], a minor, hereby consent to his/her BCYF membership and waive and release any and all rights,
causes of action and claims for damages I may have against the City of Boston, BCYF, 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 BCYF for publicity purposes. I also agree to allow BCYF 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 BCYF Community Centers and programs.
Failure to comply with these rules and expectations can lead to termination of membership.
Primary Contact Name:
Home Address:
Street Apt. City/Neighborhood Zip Code
Home: Work: Cell:
Secondary Contact Name:
Home Address:
Street Apt. City/Neighborhood Zip Code
Home: Work: Cell:
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.)
Signature of Member Date
Signature of Parent/Guardian (if member is under 18) Date
Parent/Guardian Name:
Home Address:
Street Apt. City/Neighborhood Zip Code
Home: Work: Cell:
Parent/Guardian Name:
Home Address:
Street Apt. City/Neighborhood Zip Code
Home: Work: Cell:
Youth Membership Application
The mission of Boston Centers for Youth & Families is to enhance the quality of life for Boston residents by part-
nering 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.
