Join(backup) - Boys and Girls Club of Greater Haverhill

About Us
News & Events
Registration
- After school Programming
- K-3rd Kids Club
Programming
Volunteer
Donate

Join

Member Information:

* Indicates required field

Name *

First

Last

DOB: *

Age *

Sex: *

Male Female

Address *

City *

State: *

Zip: *

School *

Grade *

Membership Status *

New Renew

Ethnicity: *

African American Asian Caucasian Hispanic Multi-Racial Native American Other

Health History

Conditions *

Athsma Behavior Disorder Convulsions Diabetes Ear Infections Heart Murmur Migraines Other

Allergies *

Drug Food Seasonal Stings Other

Please explain any check marks *

Medications *

Immunizations (Check all that apply) *

Booster DTP Series Measles (live) Rubella Tetanus Tuberculin Test

Insurance Information

Insurance Company: *

Policy / Group #: *

Policy Holder Name: *

Relationship to Member: *

Parent / Guardian Information:

Primary Contact

Name *

First

Last

Address *

Line 1

Line 2

City

State

Zip Code

Country

Relationship *

Mother Father Guardian

Cell Phone *

Work Phone *

Email *

Secondary Contact

Name *

First

Last

Relationship *

Mother Father Guardian

Address *

Line 1

Line 2

City

State

Zip Code

Country

Cell Phone *

Work Phone *

Email *

Authorization for Pick Up / Emergency Contact:

Comment *

Email *

Comment *

Submit

Boys & Girls Club of Greater Haverhill

55 Emerson Street
Haverhill, MA 01830
tel: 978.374.6171
fax: 978.912.7522
email: [email protected]

Visit Us on Social Media

Club Hours

Club Open Daily from 2:00pm to 7:00pm
Front Lobby opens at 11:00AM

© 2024 Boys & Girls Club of Greater Haverhill

About Us
News & Events
Registration
- After school Programming
- K-3rd Kids Club
Programming
Volunteer
Donate