Boys & Girls Clubs of Valdosta

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(229) 242-0676

info@bgcvaldosta.org

Online Membership Application

First Name

Middle Name

Last Name

Address

Phone Number

City

State

Zip Code

County

New Field:

School

Grade (Current Grade for After School Members)

School

Grade (Promotion Grade for summer members ONLY)

PARENT INFO

Primary Parent/Guardian Name

Relationship to Child

Home Phone

Cell Phone

Employer

Work Number

Email Address

Secondary Contact Name

Relationship to Child

Home Phone

Cell Number

New Field:

Name

Relationship to Child

Phone Number

New Field:

New Field

Name

Relationship to Child

MEDICAL INFORMATION

Allergies

Medical Problems/Needs

Insurance

If Yes, List Insurance Provider

Medicaid?

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