Membership Registration

Membership registration

Serving All Locations

MULLIN & MCADAMS CLUBHOUSE

Open Afterschool Until 6:00pm
679 Lincoln Way
Auburn, CA 95603
(530) 889-2273

Serving
1st - 8th grades
& Teen Center
9th - 12th grades

E.V. CAIN EXTENSION

Registration Full
WAITLIST ONLY
Open Afterschool Until 6:00pm
150 Palm Avenue
Auburn, CA 95603
(530) 887-8166

Serving
E.V. Cain Students
6th -8th grades

UNION PACIFIC RAILROAD CLUBHOUSE

Open Afterschool Until 6:00pm
313 High Street
Roseville, CA 95678
(916) 789-7884

Serving
1st - 8th grades

AUBURN ELEMENTARY EXTENSTION

Registration Full
WAITLIST ONLY
Open Afterschool Until 6:00pm
11400 Lariat Ranch Rd
Auburn, CA 95603

Serving
Kindergarten - 5th grades

Cost

The Club’s cost to serve each individual member in our program is $100 monthly, but parents are only asked to provide $10 as an annual membership fee and $10 a month per Club member. Any donation above the $10 monthly fee is greatly appreciated. All donations go toward providing quality programs for our members.

Registration/registración

"*" indicates required fields

Step 1 of 9

Please complete separate registration entries for members with differing parent/guardian information.

Complete las entradas de registro separadas para los miembros con diferente información de padre / tutor.

Preferred Language*

Idioma preferido

English

Español

Member Information

Información del Miembro

Name*

Nombre

First Last

What site will your child be attending after school?*

Mullin & McAdams Clubhouse – Serving Bowman, Skyridge and Alta Vista students

Teen Center – Serving Placer High School students

E.V. Cain Extension – serving EV Cain students

Auburn Elementary Extension – Serving Auburn Elementary

Union Pacific Railroad Clubhouse – Roseville grades 1st – 8th

Gender*

Sexo

Male

Female

Ethnicity*

Etnicidad

Birth Date (must be at least 6 years old to attend)*

Fecha de Nacimiento (debe tener 6 años para asistir)

Address*

Dirección de Correo

Street Address Address Line 2 City State ZIP Code

Current School*

Escuela Actual

Grade*

Grado

Shirt Size*

Talla de camisa

Primary Parent/Guardian Information

Información del Padre/Guardián Principal

Name*

Nombre

First Last

Mobile Phone*

Teléfono Celular

Home Phone

Teléfono de Casa

Work Phone

Teléfono de Trabajo

Address*

Dirección de Correo

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Employer*

Empleador

Job Title

Is this Parent/Guardian a member of the military?*

¿Es el padre/guardián del niño miembro del ejército militar?

Yes / Si

Branch [Start Date - End Date]

Rama [Fecha Inicial - Fecha de Salida]

Is there another Parent/Guardian?*

Hay otro Padre/Guardián?

Yes / Si

Additional Authorized Pick Ups – Other person(s) authorized to pick up. Please list any additional people you would like to authorize to pick up your child(ren).

Otra(s) Persona(s) autorizada(s) para recoger al miembro. Indique cualquier persona adicional que le gustaría autorizar para recoger a su(s) hijo(s).

Authorized Pick-Up 1

Otra persona autorizada para recoger al miembro

First Last

Relationship to Member

Relación con el Miembro

Phone

Telefono

Authorized Pick-Up 2

Otra persona autorizada para recoger al miembro

First Last

Relationship to Member

Relación con el Miembro

Phone

Telefono

Authorized Pick-Up 3

Otra persona autorizada para recoger al miembro

First Last

Relationship to Member

Relación con el Miembro

Phone

Telefono

Authorized Pick-Up 4

Otra persona autorizada para recoger al miembro

First Last

Relationship to Member

Relación con el Miembro

Phone

Telefono

Authorized Pick-Up 5

Otra persona autorizada para recoger al miembro

First Last

Relationship to Member

Relación con el Miembro

Phone

Telefono

Agreements

Acuerdos

Parent / Guardian Agreement*

Acuerdo del Padre / Guardián

I hereby give permission for my child to become a member and participate in activities of the Boys & Girls Club of Placer County. • I understand the Club is not responsible for the time or manner in which my child may arrive or leave the Club. The Club and its properties are not responsible for personal injury or loss of property. • I agree to pick up or have an emergency contact pick up my child within one hour if requested by the Club. • I permit the Club to use photographs or video of my child participating in Club activities and waive all rights for compensation including but not limited to print and social media. • In the event of an emergency, I authorize the Club to seek medical attention and transportation for my child if deemed necessary.

Por este medio doy permiso para que mi niño sea un miembro y participe en las actividades del Boys & Girls Club de Placer County. • Entiendo que el Club no es responsable por el tiempo o la manera en que mi niño llega o sale del Club. El Club y sus propietarios no son responsables por daño personal o pérdida de propiedad. • Estoy de acuerdo en recoger o que alguno de mis contactos de emergencia recoja al niño dentro de una hora se esto es solicitado por el Club. • Autorizo que el Club use fotografías o video de mi niño participando en actividades del Club y renuncio a todos mis derechos de compensación incluyendo pero no limitándose a medios sociales o impresos. • En caso de una emergencia, autorizo al Club para buscar atención médica y transportación para mi niño si se considera necesario.

Authorization for Interagency Exchange of Confidential Information*

Autorización para Intercambio de Información Confidencial Entre Agencias

I give permission for the release and exchange of confidential information from the following sources in order to provide programs and coordinate services for my child: (Auburn Union School District, Placer High School District, Bowman-Ackerman School District, Roseville City Elementary School District, Roseville Joint High School District, Dry Creek Joint Elementary School District, Auburn Police Department, Roseville Police Department, Placer County Sheriff Department, Department of Health & Human Services, Placer County Probation Department, Boys & Girls Club of America, United Way & Stand Up Placer). I understand that my records are protected under federal confidentiality regulation and cannot be disclosed without my written consent unless otherwise provided for in the regulations. I may withdraw this consent at any time except to the extent that action has been taken in reliance on it. This release will be effect as long as the child has a membership with the Club. If at any time membership is terminated, I understand no fees will be returned to me.

Doy permiso para la entrega y el intercambio de información confidencial de las siguientes Fuentes para proveer programas y coordinar servicios para mi niño: (Auburn Union School District, Placer High School District, Bowman-Ackerman School District, Roseville City Elementary School District, Roseville Joint High School District, Dry Creek Joint Elementary School District, Auburn Police Department, Roseville Police Department, Placer County Sheriff Department, Department of Health & Human Services, Placer County Probation Department, Boys & Girls Club of America, United Way & Stand Up Placer). Entiendo que mis récords están bajo protección de las regulaciones federales sobre confidencialidad y no pueden ser revelados sin mi consentimiento escrito a no ser que lo provean dichas regulaciones. Puedo retirar este consentimiento en cualquier momento excepto en la medida en la cual se haya tomado acción al respecto. Este permiso estará en efecto mientras mi niño tenga una membresía en el Club. Si en cualquier momento la membresía es terminada, entiendo que no recibiré ningún reembolso.

Payment Agreement*

Acuerdo de Pago

I agree to pay the monthly program fee by the first of each month. Monthly fees are due regardless of attendance. Additional fees may apply to non-school days or camp weeks. If at any time membership is terminated, I understand no fees will be returned to me.

Estoy de acuerdo en pagar todos los honorarios por el primer día del mes. Las tarifas mensuales se vencen independientemente de la asistencia. Se puede aplicar tarifas adicionales a días no escolares o semanas de campamento. Si en cualquier momento la membresía es terminada, entiendo que no recibiré ningún reembolso.

Parent or Guardian Agreement / Firma del Padre/Guardián*

I understand that typing my name constitutes a legal signature confirming that I acknowledge and agree to the above Parent/Guardian Agreement, Authorization for Interagency Exchange of Confidential Information and Payment Agreement. / Entiendo que escribir mi nombre constituye una firma legal que confirma que reconozco y acepto el anterior Acuerdo de padre / tutor, la Autorización para el Intercambio interinstitucional de información confidencial y el Acuerdo de pago.

First Last

Signature*

Firma

Comments

This field is for validation purposes and should be left unchanged.

Membership Registration