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Membership Request
Please complete for all adults that reside in the home
(if you have more than 2 adults please use the comment box below to provide their information)
Club Selection
*
Booneville - Main Club
Magazine Site
Teen Center
Select One
*
Indicates required field
Adult #1
*
First
Last
Please complete for all adults that reside in the home (if you have more than 2 adults please use the comment box below to provide their information)
Employment Status
*
Not Employed
Part Time
Full Time
Working from home
Please select all that apply
Email
*
Phone Number
*
Adult #2
*
First
Last
Employment Status
*
Not Employed
Part Time
Full Time
Working from home
Please select all that apply
Email
*
Phone Number
*
Please complete for all minors age 6-12 that are requesting membership (if you have more than 4 minors requesting membership please use the comment box below to provide their information)
Minor #1
*
First
Last
Age
*
Previous Club Member
*
Yes
No
Minor #2
*
First
Last
Age
*
Previous Club Member
*
Yes
No
Minor #3
*
First
Last
Age
*
Previous Club Member
*
Yes
No
Minor #4
*
First
Last
Age
*
Previous Club Member
*
Yes
No
If your membership is accepted do you agree to the minor participating in a daily health screening prior to entrance to the Club?
*
Yes
No
If your membership is accepted do you agree to pick up or have an emergency contact pick up the minor within 15 minutes of notification of an illness?Choose One
*
Yes
No
If your membership is accepted do you and your minor child agree to assist the Club in following the conditions and requirements of CDC / ADH guide lines? Choose One
*
Yes
No
Comment Box. Please provide any additional information that we need to know for consideration.
*
Submit
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