Mathews-Dickey Boys' & Girls' Club

Child's Last Name * Child's First Name *  Middle         Sex:       Age: Male  Female Address1 *                 City *    State* Zip *   AA AE AK AL AP AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA MA MD ME MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VA VI VT WA WI WV WY   Phone #s         Home                                                Work Fax:   X Email *                 Date of Birth: Birthplace:    School: Grade: Name of Mother and/or Guardian: Work Phone: Mother/Guardian Employment: Cell/Pager: Name of Father and/or Guardian: Work Phone: Father/Guardian Employment: Cell/Pager: Emergency Contact Name: Relationship: Home Phone: Work Phone Do you have Medical Insurance? Yes   No:       Insurance Information: Phone:           Baseball Dramatics Soccer Basketball Football Summer Program Cheerleading Game Room Swimming Choir Tennis Junior Leadership Cooking Modeling Tutoring Dancing Pom Pom Other: Uniform Size         Please review the following and initial where required. I give my consent for my child to join the Mathews-Dickey Boys' & Girls' Club of St. Louis. As a member family of Mathews-Dickey, we accept responsibility for the proper care, usage and return of all Mathews- Dickey property, uniforms and equipment. I grant permission for my child to participate in field trips and special events scheduled for members. I understand that all precautions will be taken for the safety and welfare of my child. I will not hold the Mathews-Dickey Boys' & Girls' Club nor its Representatives responsible for any accidents incurred by my child during participation in Club programs. I clearly understood that Membership fees are not refundable under any circumstances. By my initials, I agree to the above statement: Number of brothers:  Number of sisters:     Indicate a family income range (check one) 0 to $10,000 $10,000 to $20,000 $20,000 to $30,000 $30,000 to $40,000 $40,000 to $50,000 $50,000 and above Ethnic Background African-American Asian Caucasian (White) Native -American Hispanic Other After you hit the submit button, you will be directed to the payment page! PRIVACY POLICY The Mathews-Dickey Boys’ & Girls’ Club is a non-profit, 501 (c)3 organization and contributions are tax-deductible. Information collected via this document is utilized for the express purposes of Mathews-Dickey and will not be shared any other entity without the consent of the volunteer/member/donor. The Club maintains Internet firewalls on its servers to protect financial and other data. The make corrections to your contact information, please call Barbara Washington at (314) 382-5952, ext. 234. Mathews-Dickey Boys' & Girls' Club PR & Events Department 4245 North Kingshighway Blvd. St. Louis, MO 63115 • Voice: 314.382.5952, ext. 234 • Fax: 314.389.3033 • E-Mail:  bwash-md@swbell.net • Web: www.mathews-dickey.com