Membership Form

Membership Application

Clubhouse Location Preference

Child's First Name

Child's Last Name

Date of Birth

School

Grade (2020-21)

Gender

Status

Child's Ethnicity

Street #

Street Name

Apt or Unit #

City

Zip

Total in Household

Child is Currently:

Medical Conditions, Allergies, Special Needs (include information that may assist staff in supporting your child's activities. If none, please write "none."

Please List All Medications (if any need to be administered during program hours, please fill out an Authorization for Administration of Medication form).

Medical Insurance Company

Name of Policy Holder

Household Type

Are one or both parents/guardians currently active in the military?

If yes, does your child live on military base?

Annual Household Income

Does your child qualify for free or reduced price lunch at school?

PRIMARY CONTACT First Name

PRIMARY CONTACT Last Name

Gender

New Field:

Street Name

Apt or Unit #

City

Zip

Cell Phone Number

Email Address

Home Phone number

Employer

Work Phone

SECONDARY CONTACT First Name

SECONDARY CONTACT Last Name

Gender

Street #

Street Name

Apt or Unit #

City

Zip

Cell Phone Number

Email Address

Home Phone Number

Employer

Work Phone

Additional Persons Authorized to Pick Up Child (do not include parent/guardian listed previously)

Emergency Contact #2

Emergency Contact #3

Membership Application

Contact Us

Village Clubhouse

3115 Roosevelt Street, Carlsbad 92008 760.729.0956

Bressi Ranch Clubhouse

2730 Bressi Ranch Way, Carlsbad 92009 760.683.5106

Non Program Related Administration

2730 Bressi Ranch Way, Carlsbad 92009 760.585.9073