MDYC Member App *Please fill out 1 form for each member requiring an application. "*" indicates required fields Please Select Your Location*Select LocationDetroitRoyal OakSouthfieldWe are currently at capacity at our Detroit location. Please email Linda Nabers for more information and to discuss fall enrollment for our Detroit location.HiddenPlease enter code if you have one HiddenDistance to Club Club Member InfoYouth's Name* First Name Middle Initial Last Name Youth's Date of Birth* Month Day Year HiddenDuplicate or Not HiddenAgeClub CardHiddenClub Card Previous Phone Number*Primary Address* City* ZIP* HiddenAddress Detroit Club Ethnicity/Race*please select from the menuArabicAsianBlack or African AmericanLatinoMultiracialNative AmericanOtherWhiteGenderplease select from the menuFemaleMalePrefer to self-describePrefer not to sayI identify my gender as... Grade*please select from the menuKinder1st2nd3rd4th5th6th7th8th9th10th11th12thSchool*please select from menuAchievement AcademyAddams ElementaryAdlai StevensonAdler ElementaryAllen Park Community SchoolAllen Park High SchoolAllen Park Middle SchoolAmoretti SuperioriAnderson ElementaryAngell ElementryArt and Tech of PontiacBaker Middle SchoolBates AcademyBeacon Tree ElementaryBeer Middle schoolBerkley High SchoolBerkshire Middle SchoolBethuneBirney K-8Bowling Green State UniversityBradford AcademyBrother Rice High SchoolBurney Middle SchoolBurnsCarsten Elementary/Middle SchoolCarter Middle SchoolCass Technical High SchoolCenter Line High SchoolCentral High SchoolCharlotte MasonChrysler ElementaryClarenceville High SchoolClarenceville Middle schoolClarkCommonwealth AcademyCornerstone: Madison-CarverCranbrookCrescent AcademyCrossroads Day CenterDaasDakota High SchoolDavid Ellis Academy WestDekeyser ElementaryDerbyDetroit Leadership AcademyDetroit Merit AcademyDickinson EastDistinctive College PrepDoherty ElementaryDream SceneDuke EllingtonDurfee K-8 SchoolEarly Childhood School HamtramckEastover ElementaryEdisonEdmondson ElementaryEinstein ElementaryEton AcademyFarewell Middle SchoolFarmington High SchoolFaxon AcademyFerndale High SchoolFerndale Lower ElementaryFerndale Middle SchoolFerndale Upper ElementaryFisher Lower Magnet AcademyFlicsFMSFor Kids SakeForest Park ElementaryFour Corners Montessori AcademyGlobal Heights AcademyGreat Lakes AcademyGreat Oaks AcademyGreenfield ElementaryGuardian Angels SchoolHamilton ElementaryHart Middle SchoolHazel Park High SchoolHazel Park Junior HighHenry Ford Academy Greenfield VillageHighpoint AcademyHiller ElementaryHome SchoolHoover ElementaryHope AcademyHuron AcademyIndependence ElementaryJalen Rose Leadership AcademyJane Addams elementaryJoy Preparatory AcademyKeller ElementaryKey ElementaryLakeview Jefferson MSLamphere High SchoolLarson Middle SchoolLaurus AcademyLawrence TechLeave Middle SchoolLessenger ElementaryLevey Middle SchoolLighthouse Connections AcademyLone Pine ElementaryMacArthur K-8 UniversityMacomb Dakota High SchoolMadison Craver AcademyMadison ElementaryMadison Heights High SchoolMannMartin Luther King High SchoolMath and Science AcademyMcIntyre ElementaryMeadowbrook ElementaryMiami ElementaryMichigan Virtual AcademyMomentum AcademyMonteith ElementaryMorris Adler ElementaryMorse ElementryMound Park ElementaryMunger Elementary Middle SchoolNavigatorNiji Iro ElementaryNolan ElementaryNorthwesternNorthwood ElementaryNorup International SchoolOak Park High SchoolOak Park Prep AcademyOak Park Servive Learning AcademyOak Ridge ElementaryOakland ElementaryOPPAOxford High SchoolPace AcademyPage Middle SchoolPalmer Park Preparatory AcademyParkridge ElementaryPathfinderPattengill ElementaryPear LeanPeck ElementaryPembroke ElementaryPepper ElementaryPiercePrinceton ElementaryReady 2 learnRedford Service Learning AcademyRenaissance HighRochester High schoolRogersRomulusRoose ElementaryRoosevelt McGrathRoyal Oak High SchoolRoyal Oak Middle SchoolRoyal Oak Saint MarySampson Webber AcademySchalm Elementary SchoolSchulze ElementarySheiko ElementaryShrine AcademySigma AcademySouth Lake Middle schoolSouthfield Arts and TechnologySouthfield Christian/Michigan VirtualSouthfield ElementarySouthfield High SchoolSt. Mary's Royal OakStadium Drive ElementaryStevenson ElementaryThalia TraceThirkell ElementaryThompson K-8Thurgood Marshall Elementary/middle SchoolTroy Athens High SchoolTruimp AcademyUnited Oaks ElementaryUniversity High SchoolUniversity Middle SchoolUniversity of Detroit Jesuit High School and AcademyUniversity Prep Science & Math ElementaryUprep Mark MurrayUpton ElementaryUtica High SchoolVandenberg ElementaryVanderburg World of SchoolsVirtualWaldorfWalled Lake ElementaryWalton Charter AcademyWarner Upper Elementary SchoolWashington-Parks AcademyWaterlooWaverly East IntermediateWayne ElementaryWebb ElementaryWest Bloomfield ElementaryWest Bloomfield High SchoolWest Hills Middle SchoolWest Maple ElementaryWestfield Charter AcademyWestlandWestside Christian AcademyWestview ElementaryWilkerson ElementaryWilkinson Middle SchoolWolfe Middle SchoolWood Creek ElementaryOtherAdd Your School Here* HiddenOLD School* HiddenAdditional Info/Staff NotesHousehold InfoMember Lives With - check all that apply* Both Parents Mother Father Aunt/Uncle Grandparent(s) Foster Guardian Total Number in Household Family Settingplease select from the menuMarriedSingleDivorcedRemarriedOtherFamily Incomeplease select from the menu$10,000-below$10,001-$26,650$26,651-$30,000$30,001-$33,250$33,251-$36,000$36,001-$38,550$38,551-$41,250$41,251-$44,000$44,001-abovePrograms/Services - check all that apply TANF Bridge Card General Assistance SSDI SSI Veterans Comp Day Care Voucher School Lunch Sibling Name Sibling Age Is sibling a Club member? (Y/N) Are there other siblings to enter? Yes No Sibling Name Sibling Age Is sibling a Club member? (Y/N) Sibling Name Sibling Age Is sibling a Club member? (Y/N) Member Medical InfoAllergiesMedicationsSpecial NeedsName of Physician Physician PhoneInsurance Company Policy Number Parent/Guardian InfoFirst Name of Parent/Guardian* Last Name of Parent/Guardian* Relationship* Address* City* ZIP* Email Address* Employer HiddenOLD Email Address* Phone Number*(home/cell/work)HomeCellWorkSecondary Number(home/cell/work)HomeCellWorkParent/Guardian 2This section is for the second parent/guardian. If not applicable, leave this section blank and proceed to the next section.First Name of Parent/Guardian Last Name of Parent/Guardian Relationship Address City ZIP Email Address Employer Phone Number(home/cell/work)CellHomeWorkSecondary Number(home/cell/work)HomeCellWorkEmergency ContactsPlease provide two additional emergency contacts other than the parents/guardians listed above.Contact 1: First Name* Contact 1: Last Name* Relationship to Member* Phone Number*Contact 2: First Name* Contact 2: Last Name* Relationship to Member* Phone Number*Parent ConsentConsent Agreement*Please read carefully. This is a legal document that affects your legal rights and the legal rights of the child for which you are waiving liability. This waiver and release of liability is drafted pursuant to Michigan Statute 700.5019, whereby the Michigan Legislature has granted nongovernmental, nonprofit organizations the ability to have a parent or guardian of a child release from liability economic and noneconomic damages for personal injury sustained by the minor during the specific activity for which this release is provided. 1. I affirm that I am the parent or guardian of the child list in this membership form. 2. I do freely, voluntarily, and without duress, execute this Waiver and Release of Liability and acknowledge the following terms: a. I understand that the Metro Detroit Youth Clubs (the “Club”) is organized as a Michigan nonprofit entity under the laws of the State of Michigan. b. It is my desire to have my child take part in recreational activities at the Metro Detroit Youth Clubs and hereby release, waive, discharge and covenant not to sue the Metro Detroit Youth Clubs, its departments, officers, employees and agents, from any and all liability to me, for all losses, injury, death or damage, and any claims or demands thereto, on account of injury to person or property, or resulting in my death in reference to the recreational activities of my child. I hereby covenant and agree to indemnify and save harmless, the Metro Detroit Youth Clubs, its officers, employees and agents, from any and all claims and demands, for all loss, injury, death or damage, that any person or entity may have or make, in any manner, arising out of any occurrence related to the recreational activities that my child engaged in at the Metro Detroit Youth Clubs. c. The Metro Detroit Youth Clubs have implemented the recommended protocols and preventative measures recommended by the Center for Disease Control (the ”CDC”) to help reduce the spread of COVID-19; however, the Metro Detroit Youth Clubs cannot guarantee that your child will not become infected with COVID-19. By signing this agreement, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that your child may be exposed to or infected by COVID-19 by attending the recreational activities at the Metro Detroit Youth Clubs and that such exposure or infection may result in personal injury, illness, permanent disability, and death. You understand that the risk of becoming exposed to or infected by COVID-19 at the Metro Detroit Youth Clubs may result from the actions, omissions, or negligence of yourself, your child and others, including, but not limited to, staff, volunteers, employees, instructors, desk personnel, and other children attending the recreational activities. You affirm that on behalf of your child, that he or she voluntarily agrees to assume all of the foregoing risks and accept sole responsibility for any injury to himself/herself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that the child may experience or incur in connection with his/her attendance at the recreational activities at the Metro Detroit Youth Club. On behalf of myself, my child, my heirs, and any personal representatives, I hereby release, discharge, and hold harmless the Metro Detroit Youth Clubs, its employees, agents, volunteers, instructors and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Metro Detroit Youth Clubs, its employees, agents, volunteers, instructors and representatives, whether a COVID-19 infection occurs before, during, or after attending the Metro Detroit Youth Clubs. Also, agree with the following: i. I will tell the staff of the Metro Detroit Youth Clubs of any Covid-19 related symptoms and any pre-existing condition or pain that I, any family member living with me and my child has experienced prior to the entry of the premises of the Metro Detroit Youth Clubs. ii. I will answer truthfully the health screening questions concerning my child before every visit to the Metro Detroit Youth Clubs as part of COVID protocol. d. I release and discharge Metro Detroit Youth Clubs from any claim that arises or may arise due to any first aid, medical treatment, or service rendered to me. e. The Metro Detroit Youth Clubs does not have responsibility for providing any health, medical or disability insurance coverage for me. IT IS MY RESPONSIBILITY TO ENSURE I HAVE MEDICAL/HEALTH INSURANCE FOR MY CHILD. f. I understand that my child may be involved in recreational activities at the Metro Detroit Youth Clubs that may be hazardous. On behalf of my child, I affirm that my child assumed the risk of injury or harm in those activities I choose to do and release the Metro Detroit Youth Clubs from all liability for injury, illness, death, or property damage occurring while attending any recreational activities at the Metro Detroit Youth Clubs. g. I understand the term “recreational activity,” shall be defined consistent with MCL 700.5109(7)(b) and shall be broadly construed to include any other activities as solely determined by the Metro Detroit Youth Clubs to be deemed a “recreational activity.” h. I agree that this Release is intended to be as broad and inclusive as permitted by the laws of Michigan; that this Release is governed by and will be interpreted according to the laws of Michigan; that any challenges to this release shall be filed in Oakland County Circuit Court; and I understand and agree that if I challenge this waiver and release, I will pay the actual attorney fees of the Metro Detroit Youth Club. I understand that should any part of this Release be ruled invalid by a court, the other parts will remain valid and continue to be in effect. I have read the completed application, understand the rules of the Metro Detroit Youth Clubs and request that my son/daughter be admitted into membership. I understand that the Metro Detroit Youth Clubs' facilities operate with an open door policy that allows Club members to come and go at will. If a Club member does leave the facility they may only return to the Club on the same day in the presence of their parent /guardian. It is my responsibility to be sure that my child understands the departure procedure from the Club. The Metro Detroit Youth Clubs accepts no responsibility for children who choose to leave the Club. It is my responsibility to keep my contact information up to date at the Club. I understand in the event my child is suspended from the Club no fees or dues will be refunded. I understand that all members must have the physical, mental, and emotional maturity to act and interact independently and responsively in the Club setting. For consideration for Metro Detroit Youth Clubs admitting my child into membership, and other good and valuable consideration, the sufficiency of which I acknowledge, on behalf of myself, any other parent or guardian of my child, I/we agree to indemnify and hold harmless Metro Detroit Youth Clubs, their agents, members, officers, employees, counselors, and volunteers, from any and all liability, claims, suits, demands, damages, judgments, costs, interests and expenses (including attorney's fees and all legal costs, any injury and costs of medical services, etc.) arising directly or indirectly from membership in the Metro Detroit Youth Clubs or participation or transportation of my child with regard to any activity. I further waive all claims I may have against Metro Detroit Youth Clubs, to the fullest extent permitted by law. I give my consent for photographs, in which the member may appear to be used in any way the Metro Detroit Youth Clubs may use them to support the mission of the Metro Detroit Youth Clubs. I give permission for my child to participate in surveys, discussion groups or other activities that help determine the success of Club programs. I authorize Metro Detroit Youth Clubs to obtain or share data related to my child for the purpose of program assessment. In the event that I cannot be reached in an emergency, I authorize Club staff to arrange for emergency medical attention for my child. I acknowledge I have the authority and ability to sign this Permission Form inclusive with all of its components. In the event any provision of this Form is deemed in-valid, the balance remains in full force and effect. Check box to agree to the terms above.Type Your Name To Sign* First Name Last Name Payment InformationThe annual membership fee for the Club is $50. You can pay your dues online through this membership form via our secure and encrypted payment method powered by Stripe. If you cannot pay by credit card, please contact the Club. Your membership will be valid until 12/31/2023.Annual MembershipHidden2023 App HiddenRecent Att HiddenBus Annual Membership Do you have a coupon code to enter? Yes No Coupon Credit CardCard Details Cardholder Name Total For Membership Through 12/31/2023 Please click the submit button. It may take 10-30 seconds for the form to go through, so please be patient after you click submit. Thank you!