1. Member Information:

First Name (required)

Last Name (required)

Date of Birth (required)

Age

Gender

Address - Street no. - Apt/Unit (if applicable) (required)

City (required)

Postal Code (required)

Member Home Phone

Member Cell Phone

Member Email Address (required)

2. School Information:

Member's School

Grade

2. Family Information:

Member resides with:
Both ParentsMotherFatherGuardian

Mother/Guardian (last name and first name)

Address

Same Address as Member

Home Phone

Same Home Phone as Member

Cell Phone

Work Phone

Email Address

Father/Guardian (last name and first name)

Address

Same Address as Member

Home Phone

Same Home Phone as Member

Cell Phone

Work Phone

Email Address

Additional Information

The Boys and Girls Club of Ottawa is fortunate to provide barrier-free programming due to our funders, can you please assist us in obtaining additional information about the children we serve. Do you consider your child to be included in any of the following groups? (check all that apply)

Immigrant/New CanadianRural ResidentMember of Visible MinorityFrancophoneFirst Nations, Metis and/or InuitPerson with a DisabilityMilitary FamilyNot a member of these groupsI prefer not to answerLGBTTIQQ2SA

Parental Authorization: Your responses will help us maintain a barrier free, no cost program

My child may participate in surveys for program evaluation.

YesNo

Initials

My child may appear in photographs (printed material) used for reporting, publicity purposes
and/or promotion of the Boys and Girls Club of Ottawa.

YesNo

Initials

My child may appear in photographs (internet / media) used for reporting, publicity purposes and/or promotion of the Boys and Girls Club of Ottawa.
YesNo
Initials

I have read and understood The Privacy Policy

I, the undersigned, the parent or guardian, having applied to the Boys and Girls Club ("the Club") on behalf of my child or ward for membership in the Club, and in consideration for acceptance by the Club of my application, do hereby give permission for my child or ward to participate in the Club and their programs including all scheduled outings, unless I advise in writing to the contrary.
Having investigated the activities and resources of the Club to my satisfaction, I understand that due care and attention will be given to the safety of all participants including my child or ward, but that the Club, its officers and directors, staff and volunteers cannot be held liable for any injury or loss, howsoever caused, and I release the Club, its officers and directors, staff and volunteers on behalf of my child or ward, from any liability and from all claims arising, directly or indirectly, from participation by my child or ward in Club activities. I further understand that the Club reserves the right to remove my child or ward from the program if the Club deems it necessary to ensure the safety and well being of other participants.

Please type your full name in this box to confirm your signature (required)

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