Mathews-Dickey

4245 North Kingshighway Blvd.
St. Louis, MO 63115
(314) 382-5952

 Payment Method:
 Cash
Check
Debit
Money Order
Registration Date:
MEMBERSHIP APPLICATION

Mathews-Dickey Membership fee is $25

Child's First Name *  Middle         Sex:       Age:
Male  Female
       
       
   State* Zip *  
 
       
                                                
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:    
   

Check what programs you are interested in! 
Check all that apply!

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

Check sent separately to the attention of the Membership Services
Department at the address below
Please bill the above total to my credit card.  (I am calling in my credit card information)

When you have completed and submitted the form by pressing on Submit button.


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
Attn. Membership Services
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

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