Guest | North Penn Valley Boys & Girls Club

GUEST PERMISSION

To attend Club activities as a guest, 6-18 year-olds must have slip filled out completely and signed by a parent/guardian. Youth/Teens may attend once as a guest. To return to the Club, a membership must be obtained.

Guest Information

*Date of Visit:

Day Month Year

*Guests Full Name

E.g.: Jonathan Doe

*Age

*Gender

Male Female

*Which Club will you Visit?

*Which Activity are you Coming For?

Home Information

*Home Phone

E.g.: 215 555 8181

*Parent Cell Number

E.g.: 215 555 8181

*Address

E.g.: 16 Susquehanna Avenue

Address 2

E.g.: Apt, floor, suite, etc.

*City

E.g.: Lansdale

*State

E.g.: Pennsylvania

*Zip/Postal code

E.g.: 19446

Family Information

*Parent/Gaurdian Full Name

E.g.: Jonathan Doe

*Email address

E.g.: jonathan@doe.com

*Medical Problems

E.g.: Allergies, ADHD, etc.

*Medications

E.g.: Allegra, Ritalin

The following information below is necessary for our records and the funding our organization receives. The answer you provide is completely confidential. Your cooperation in providing this information is both appreciated and necessary.

*Ethnicity

I agree that the Boys and Girls Club will not be responsible for any accident to my son/daughter while on the premises or
while engaged in any of its activities.

I understand the Club reserves the right to suspend my child from the premises due to the violation of Club rules or
inappropriate behavior.

I give consent to the Boys and Girls Club to not release my child if I, or anyone authorized to pick up my child, appear to be
visibly intoxicated or under the influence of a controlled substance.

I give consent for photography/video, in which my son/daughter may appear, to be used in any way the Boys and Girls Club may
care to use them.

I understand the Club is not liable for any loss of or damage to personal property of Club members/guests and am aware that
it is highly recommended that valuable objects are not brought into the building.

In return for allowing my child to use Club facilities I agree the Club has the right to search my child's personal property at the
sole discretion of the directors and employees of the Club.

* As the parent, I agree to the terms stated above

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Winter 2011