Online Membership Application

Afterschool Program 2025-26

Please note: Olivet Boys & Girls Club will not accept incomplete Membership Applications. All information must be provided. If there is an information field which does not apply, please write N/A. Additionally, your child’s membership in Olivet Boys & Girls Club is not finalized/active until you are contacted by an Olivet staff member and payment for the associated membership fee is received.

Club Location enrolling at:(Required)

Center for the Arts (CFA) - 328 Walnut street Reading, PA 19601

Clinton - 677 Clinton street Reading, PA 19601

Mulberry - 400 N 10th Street Reading, PA 19604

Oakbrook - 1161 Pershing Blvd Reading, PA 19611

PAL (at Lauer's Park Elementary) - 251 N 2nd Street Reading, PA 19601

Pendora - 330 S 19th street Reading PA 19606

Youth Membership Application

Member Name(Required)

First Last

Address(Required)

Street Address City ZIP / Postal Code

Date of Birth(Required)

Age(Required)

T-Shirt Size(Required)

Preferred Name/ Nickname(Required)

Pronouns

Gender(Required)

Race(Required)

American Indian / Alaska Native

Asian

Black / African-American

Hawaiian Native / Pacific Islander

Hispanic / Latino

Middle Eastern / North African

White / Caucasian

Two or More Races

Other

Ethnicity(Required)

Hispanic

Non-Hispanic

Other Race

School (2025-2026)(Required)

Grade (2025-2026)(Required)

School Program Lunch(Required)

Free

Reduced

Not Eligible

Contact Information

All contacts listed below are authorized to pick up the member.

Primary Parent/Guardian Name(Required)

First Last

Primary Parent/Guardian Date of Birth(Required)

Primary Parent/Guardian Relation to Member(Required)

Primary Parent/Guardian Phone(Required)

Primary Parent/Guardian Work Phone(Required)

Primary Parent/Guardian Email(Required)

Secondary Parent/Guardian Name(Required)

First Last

Secondary Parent/Guardian Date of Birth(Required)

Secondary Parent/Guardian Relation to Member(Required)

Secondary Parent/Guardian Phone(Required)

Secondary Parent/Guardian Work Phone(Required)

Secondary Parent/Guardian Email(Required)

Emergency Contact Name(Required)

First Last

Emergency Contact Date of Birth(Required)

Emergency Contact Relation to Member(Required)

Emergency Contact Phone(Required)

Emergency Contact Work Phone(Required)

Other Person Authorized to Pick Up My Child Name

First Last

Other Person Authorized Relation to Member

Other Person Authorized Phone

Allergy Information

In the event of a food allergy, medical documentation/doctor's note is required so that alternative meals/snacks may be made available to the member.

Food Allergies / Dietary Restrictions(Required)

Yes

Food Allergies / Dietary Restrictions (Choose All the Apply)

Additional Food Allergies / Dietary Restrictions

Environmental Allergies(Required)

Yes

Environmental Allergies (Choose All That Apply)

Bee Stings

Grass

Pollen

Dust

Mold

Other

Additional Environmental Allergies

Other Allergies(Required)

Yes

Other Allergies (Choose All That Apply)

Latex

Lotions

Perfumes/Colognes

Other

Additional Other Allergies

Medical Information

Diagnosed Medical Condition(Required)

Yes

Diagnosed Medical Condition (Choose All That Apply)

Additional Diagnosed Medical Condition

Does the member use an inhaler?(Required)

Yes

Does the member use an EpiPen?(Required)

Yes

Does the member use insulin?(Required)

Yes

List All Medications Which The Member Takes(Required)

Medication Dosage and Time Taken(Required)

Does the member self-administer medication?(Required)

Yes

Significant Medical History (surgery, injuries, serious illnesses)(Required)

List any other physical or mental limitations(Required)

Insurance Information

Does the member have health insurance?(Required)

Yes

If Yes, is the health insurance through Highmark Wholecare?

Yes

Insurance Company(Required)

Policy Number(Required)

Physician Name(Required)

Physican Phone Number(Required)

Household Information

The information in this section is required by Olivet Boys & Girls Club because it is needed by several of the organizations which provide Olivet with financial support. When Olivet reports household information to those organizations, your family's personally-identifiable information is never shared. Additionally, when household information is reported, it is reported as anonymous parts of totals/averages for entire club sites or the organization as a whole, rather than as specific households. For example, Olivet may report the average household income of all the households of its youth members (without associating names), but Olivet would not report the household income or information of the family of one specific member.

Household Composition (Check all that apply)(Required)

Other Household Composition

How many members are in your household, including yourself?(Required)

Number of Household Members Under 18?(Required)

Number of Household Members Over 65?(Required)

Are any household members physically disabled?(Required)

Yes

Do any household members belong to the military?(Required)

Yes

Which Military Branch?

Primary language spoken at home?(Required)

Primary language spoken by the child?(Required)

Annual household income(Required)

Is there a restraining order against any individual that would prevent contact with this member?(Required)

Yes (if yes, must provide legal documentation)

Name of Person with restraining order

Relation to member

Policy Agreements

Emergency Medical Care(Required)

In the event of an emergency involving my child, I grant Olivet Boys & Girls Club permission to contact emergency medical personnel and, pending their arrival, take those actions that Olivet Boys & Girls Club deems to be in the best interest of my child.

Allergies and Dietary Restrictions(Required)

Olivet Boys & Girls Club and its food providers make every attempt to identify ingredients that may cause allergic reaction for those with food allergies. Every effort is made to instruct our staff members on the severity of food allergies. However, there is always risk of contamination. I, the undersigned, hereby understand that Olivet Boys & Girls Club will not be held liable for my child's adverse reactions to food consumed, or items which he/she may come into contact while eating. I, the undersigned, hereby affirm that my child's allergy and dietary restriction information provided herein is accurate to the best of my knowledge. I understand that failure to disclose my child's medical conditions(s) may affect my child's eligibility for membership with Olivet Boys & Girls Club.

Medical Information(Required)

I, the undersigned, hereby affirm that my child's medical information provided herein is accurate to the best of my knowledge. I understand that failure to disclose my child's medical condition(s) may affect my child's eligibility for membership with Olivet Boys & Girls Club.

Sharing of Information with Highmark Wholecare/Gateway Health(Required)

Olivet Boys & Girls Club maintains a partnership with Highmark Wholecare/Gateway Health, wherein Highmark Wholecare provides limited financial support - for children who are covered under their plans - towards Olivet Boys & Girls Club membership and weekly fees. I, the undersigned, hereby grant permission for Olivet Boys & Girls Club to share my child's information with Highmark Wholecare/Gateway Health, for the sole purpose of determining his/her eligibility for financial support of his/her Olivet Boys & Girls Club membership and weekly fees.

Program Participation(Required)

In order that my child may benefit from the programs/activities of Olivet Boys & Girls Club, I, the undersigned hereby give permission and consent for my child to participate in any and all activities sponsored by Olivet Boys & Girls Club. I understand that such activities, including but not limited to field trips, athletics, and recreational gym activities, involve inherent risks. I release Olivet Boys & Girls club fomr any and all claims for injuries to my child, and any and all expenses or losses occasioned thereby, while engaged in such activities.

Transportation(Required)

I, the undersigned, understand that transportation will be provided by Olivet Boys & Girls Club so that my child may participate in certain additional programs and activities, including but not limited to the arts, educational field trips, and intramural sports. I understand that if my child is not at his/her Olivet Boys & Girls Club location by or before the designated pick-up time on a particular day, that he/she may not be able to participate in the activity on that day. I understand that transportation involves inherent risks and hazards, and I release Olivet Boys & Girls Club from any and all claims for injuries to my child, and any and all expenses or losses occasioned thereby, while utilizing transportation provided by Olivet Boys & Girls Club or its contractors.

Photographs(Required)

I, the undersigned, grant permission for Olivet Boys & Girls Club and its program partners to take and use photographs, slides, and videotapes of my child for the purpose of program evaluation, social media, and public relations for Olivet Boys & Girls Club.

No, I do not grant permission for Olivet Boys & Girls Club and its program partners to take and use photographs, slides, and videotapes of my child for the purpose of program evaluation, social media, and public relations for Olivet Boys & Girls Club.

Belongings(Required)

I, the undersigned, understand that my child should not bring toys, cell phones, electronics, or other items from home, and that Olivet Boys & Girls Club is not responsible for any lost, damaged or stolen items. I understand that my child may be required to turn in his/her cell phone or other belongings with Olivet Boys & Girls Club staff.

Dismissal & Pick-Up Status

I, the undersigned, hereby understand that, for the purpose of safe dismissal procedures, Olivet Boys & Girls Club categorizes youth club members into pick-up statuses of either "Walkers" or "Parent/Guardian Pick-Ups." I understand that "Walkers" are those whose parents have provided Olivet Boys & Girls Club with written permission to dismiss their children, without a parent/guardian or approved contact present, at the designated Walker dismissal time. I understand that "Parent/Guardian Pick-Ups" are those children whose parents have not provide such permission and who therefore are required to be picked up by one of the approved contacts listed in their Membership Applications. I understand that children designated as "Parent/Guardian Pick-Ups" must be picked up the designated "Parent/Guardian Pick-Up" dismissal time. I understand, that, if I designate my son/daughter as a "Parent/Guardian Pick-Up," then I or another approved contact listed on this Membership Application must be present by or before the designated pick-up time to pick up my child, and that failure to do so will result in the assessment of fines against me ($15.00) for every 15 minutes late past the designated pick-up time). I understand that, in the event of an anticipated late pick-up of my child, I must make Olivet Boys & Girls Club aware ahead of time. I understand that I cannot change my child's pick-up status, except by filling out the designated Olivet Boys & Girls Club forms for the pick-up status changes. I understand that Olivet Boys & Girls Club cannot accept verbal permission (including verbal permission over the phone) for dismissal of "Parent/Guardian Pick-Ups" without an approved parent/guardian or contact present. I understand that failure to abide by this policy may result in my child no longer being able to attend Olivet Boys & Girls Club programs.

Dismissal & Pick Up Status(Required)

My child will be a "Walker." I, the undersigned, grant Olivet Boys & Girls Club permission to dismiss my child at the designated "Walker" dismissal time, without a parent/guardian present to pick him/her up. I understand that Olivet Boys & Girls Club is not responsible for monitoring my child after he/she is dismissed from the Club.

My child will be a "Parent/Guardian Pick-Up." My child is required to be picked up by an approved contact listed on this Membership Application. I understand that my child is required to be picked up no later than the last Parent Pick-Up time, or I may accrue late fees.

Signature

I, the undersigned, certify that I have thoroughly read and understood the contents of this Membership Application. I certify that the information which I have provided is accurate. I understand that if I submit false or incorrect information, I may be subject to legal action.

Please type your full name in the box below. This acts as your signature.(Required)

Signature Agreement(Required)

I agree to my electronic signature above.