Membership Form

Special Membership Free for Siblings

First Name

Middle

Last Name

Nickname

Age

Birthday

Gender

Male Female

Address

Bario

Home Phone

Work Phone 1

Work Phone 2

Email 1

Email 2

Cell Phone 1

Cell Phone 2

School Information

Name School

Grade

Current Teacher

General Information

Can Member Swim

Yes No

Please Indicate any Medical Problems, Allergies and/or behavior problems

Please Indicate any Medication Presently Taking

Mother's Name

Father's Name

Name Of Guardian (if different from mother or father):

Emergency Contact Name

Emergency Contact Phone Number

List additional people to pickup your child

Name Person 1

Phone Person 1

Name Person 2

Phone Person 2

Agree with Terms

I understand that Hupsakee Kids Club is not responsible for lost or stolen items. Parents and Club members are responsible for their own transportation to and from the Club. I give permission to the Hupsakee Kids Club to seek emergency medical treatment for my minor child if I cannot be reached. I will be responsible for any/all costs of medical attention and treatment. I give permission for my child’s picture, moving pictures, or any other graphic depiction or likeness, to be used by Hupsakee Kids Club and its activities. I also understand who the Hupsakee Kids Club is not, nor does it claim to be, a licensed day care center. I have read the completed application and this form, understand the rules of Hupsakee Kids Club and request my child to be admitted into membership.

Name of Person that will Sign this form