Member's Name *

First Name

Last Name

Dat of Birth (DOB) *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Require pickup by Parent/Guardian? *

Yes

No

Eligible for free lunch? *

Yes

No

Individualized Education Plan (IEP) *

Yes

No

Doctor Name

First Name

Last Name

Doctor Phone

(###)

###

####

Permission for Treatment by Doctor/Hospital? *

Yes

No

Serious health problems? *

Yes

No

Medications? *

Yes

No

Single parent *

Yes

No

Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Data Collection *

I hereby authorize the West County Salesian Youth Club (WCSYC) to gather information through online or written surveys, questionnaires, interviews, and focus groups from the minor child listed on this application. Any information obtained will be treated with strict confidentiality. Collected data will be aggregated and devoid of any individual identifiers. Summarized findings may be shared with WCSYC staff, relevant authorities, donors, and community stakeholders for program evaluation and to demonstrate the impact of the Club on its members. This authorization can be revoked at any time by submitting a written request to WCSYC.

I agree

Technology *

By checking this box, you acknowledge that as a member of the West County Salesian Youth Club (WCSYC), your child may have access to the Internet. Despite the Club's rules against such behavior and the precautions taken to prevent it, there remains a possibility that your child may encounter inappropriate content online. WCSYC cannot be held responsible for any unauthorized access to such content.

I agree

Transportation *

By checking this box, you acknowledge that parents and Club members are hereby advised that they are responsible for arranging their own transportation to and from the Club, unless otherwise explicitly specified, including the act of walking.

I agree

Data Sharing *

By checking this box, I authorize the West County Salesian Youth Club (WCSYC) to share information about the minor child listed on this application for research purposes and/or to evaluate the program’s effectiveness with relevant organizations. Information that may be disclosed includes details provided on this membership application form, information provided by the minor child’s school or school district, and other data collected by WCSYC, such as information gathered through surveys or questionnaires. All shared information will be kept confidential. This authorization can be revoked at any time by contacting WCSYC in writing.

I agree

Press/Media *

By checking this box, I authorize the use of my child’s picture, video image, or any other graphic depiction or likeness by the West County Salesian Youth Club (WCSYC), its affiliates, or donors. I understand that neither my child nor I will receive payment for the use of such materials.

I agree

Miscellaneous *

By checking this box, I acknowledge the following: I understand and acknowledge that the West County Salesian Youth Club (WCSYC) is not liable for lost or stolen items. Each Club retains the right to make membership decisions based on its resources and staff capacity. WCSYC reserves the right to decline applications, rescind enrollments, or suspend youths who cannot successfully engage with other club members. Your child’s safety is of utmost importance, and every effort will be made to ensure their health and welfare while under our care. However, WCSYC is not liable for any harm, injury, or illness that may occur as a result of your child’s participation in Club activities. In case of harm, injury, or illness during participation, any resulting hospital, medical, or related costs will first be sought from your or your spouse's accident, medical, or hospital insurance. In the event of a complaint against WCSYC, the complainant agrees to cover WCSYC's legal fees. I understand that WCSYC is a drop-in facility and not a licensed day care provider. I accept responsibility for instructing my child on when they are permitted to leave the Club premises and for informing staff accordingly. WCSYC is not liable for any consequences if my child leaves the facility or program without proper approval or consent.

I agree

Name *

First Name

Last Name