MAJOR ADAMS COMMUNITY COMMITTEE

125 N. HOYNE AVE

CHICAGO, IL 60612-22437

2021-2022

MEMBERSHIP APPLICATION

Date: ________________,2022

First Name: ____________________________   Last Name: ___________________________

Birthdate: ____________________ ______, 20_____  Male_______   Female _______

Address: _________________________ City _________________ Zip _______________

Phone: (_______) _______-__________   Email Address ______________________@_____.______

Race Ethnicity:  Asian        A.A.         Caucasian        Native American        Latino/Hispanic

Primary Language:    English        Spanish       Other   ________________

Do minor/you Have any Special Needs or Disabilities?      YES          NO

Does minor/you have any Physical Restrictions?   YES          NO    

Parent/Guardian (who you live with) _________________________ Phone (_____)______-________

In case of emergency, contact?

Relationship: Mom          Dad           Grandparent         Sister          Brother      Relative           Other(circle one)

Name   _____________________________  Phone _____________________

Alt Name ____________________________Phone _______________

Are you currently enrolled in school?     YES   or    NO

Current/Last school attended   ______________________

Current Grade  (highest completed)   _________

How did you hear about us? _______________

HOUSEHOLD INFORMATION

Do you or your family receive other services from IDHS?

TANF  /   Medicaid   /   SNAP   /   Other   /None

Household Type:  2 Parent _____   1 Parent   ______   Guardian _____  Relative ____

House-hold size: __________

Rent ___     Own ___    Temporary Housing ____

Health Insurance?    Yes ____     No ____

Income Source (Check all that apply): Employment Only ____   Pension ____   TANF ____   SSI/P3 ____ Earn Fare ____ Unemployment ____ other ____  

No Source of Income ____

Monthly Household Income:  

$0 - 2,058 ____    $2,059 - $2,938 ___   $2,939 - $3,938 ___   $3,938 + ___

MEDICATION

Are you on any Medication?    Yes ____     No ____

Medical Condition ____________________

Medication Name/Type _________________

Self-Administered ____ Other _____________ None _______

PARENT/GUARDIAN PERMISSION AND RELEASE/WAIVER STATEMENT

I CERTIFY THAT THE ABOVE INFORMATION IS CORRECT.  I GIVE MY PERMISSION FOR THE FOLLOWING: (1) THE ABOVE NAMED MINOR CHILD TO PARTICIPATE IN ACTIVITIES AT, OR ON SITE APPROVED BY MAJOR ADAMS COMMUNITY COMMITTEE (2) ILLINOIS DEPARTMENT OF HUMAN SERVICES AND THE CHICAGO DEPARTMENT OF HUMAN SERVICES TO WRITE ARTICLES ABOUT, PHOTOGRAPH AND OR VIDEO/FILM THE ABOVE NAMED MINOR CHILD FOR PUBLICATION PURPOSES (BUT IN NO WAY TO BE USED IN AN ILLEGAL MANNER); AND (3) THE ABOVE NAMED MINOR CHILD’S SCHOOL DISTRICT OR SCHOOL TO RELEASE REPORT CARD, GRADE ACHIEVEMENT, GRADUATION INFORMATION, ATTENDANCE AND BEHAVIOR INFORMATION.  

THE MACC IS NOT RESPONSIBLE FOR LOSS OR THEFT OF CELL PHONES, COATS OR ANY OTHER PERSONAL ITEMS.  ALSO, IF A MEDICAL EMERGENCY OCCURS, GIVE PERMISSION FOR MEDICAL CARE TO BE OBTAINED FOR THE ABOVE NAMED MINOR CHILD. FURTHER, ANY AND ALL CLAIMS OF LIABILITY ARE HEREBY WAIVED AGAINST THE MACC AND THEIR BOARD OF DIRECTOR, GOVERNORS, OFFICERS, EMPLOYEES, VOLUNTEERS, AFFILIATES, AGENTS OR ASSIGNS REGARDING THE ABOVE NAMED MINOR CHILD.

Parent or Adult Signature: _______________________ Date: ______________

For additional program information, please contact Mr. Darryl Gillespie or Sherita Butler at 312-421-6903