Tell us why you love the Club in a short 250 word essay an qualify to win a brand new XBOX!

Please Verify if you are a TEEN or FAMILY participating.

I am a TEEN I am a FAMILY

Name

Phone number

My child or Myself is currently enrolled in the Boy's & Girls Club program. Please give information on all enrolled member in the household. If you only have one participating club member or are submitting as a TEEN member please only complete information for one.

Member's Name

Members grade

Members Name

Members grade

Members Name

Members grade

Members Name

Members grade

What makes the Club special to you? Please write a 250 word essay:

AGREEMENT

I agree that the provided information is accurate and although will be kept confidential, can be used to better the club through grant and/or additional funding opportunities. *IF I AM A TEEN I AGREE THAT I HAVE MY PARENT/GAURDIANS PERMISSION TO COMPLETE AND SUBMIT THIS FORM.