Boys & Girls Club Registration Form

1
Child 1 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
Gender
T Shirt Size
Address
City
IN
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
2
Child 1 - Academic Information
2019 / 2020 School Attended
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2019 / 2020 Grade Level
Yes
No
2019 / 2020 Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
3
Child 1 - Education Programs* This field is required.Is this child part of any of the following programs? If not please simply select "none" as your option.
Special Education
LEP
Gifted And Talented
None
4
Child 1 - Race/Ethnicity* This field is required.Please check all that apply. Hispanic Or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race
White
Hispanic Or Latino
Black or African American (Not Hispanic)
Native Hawaiian Or Pacific Islander
Native American
Multiracial
5
Child 1 - Primary Language* This field is required.
English
Spanish
6
Child 1 - Medical (Optional)Please list any medications, allergies or medical conditions that would prohibit or limit participation in any activities. If there are none please proceed to the next section.
Huge
Large
Normal
Small
Ok
Ok
7
Do you need to register more than 1 child?* This field is required.
YESNO
8
How Many More?* This field is required.Please select the amount of extra applicants that will have to be registered.
1
2
3
4
5
9
Child 2 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
Gender
T Shirt Size
Address
City
IN
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
10
Child 2 - Academic Information
2019 / 2020 School Attended
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2019 / 2020 Grade Level
Yes
No
2019 / 2020 Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
11
Child 2 - Education Programs* This field is required.Is this child part of any of the following programs? If not please simply select "none" as your option.
Special Education
LEP
Gifted And Talented
None
12
Child 2 - Race/Ethnicity* This field is required.Please check all that apply. Hispanic Or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race
White
Hispanic Or Latino
Black or African American (Not Hispanic)
Native Hawaiian Or Pacific Islander
Native American
Multiracial
13
Child 2 - Primary Language* This field is required.
English
Spanish
14
Child 2 - Medical (Optional)Please list any medications, allergies or medical conditions that would prohibit or limit participation in any activities. If there are none please proceed to the next section.
Huge
Large
Normal
Small
Ok
Ok
15
Child 3 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
Gender
T Shirt Size
Address
City
IN
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
16
Child 3 - Academic Information
2019 / 2020 School Attended
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2019 / 2020 Grade Level
Yes
No
2019 / 2020 Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
17
Child 3 - Education Programs* This field is required.Is this child part of any of the following programs? If not please simply select "none" as your option.
Special Education
LEP
Gifted And Talented
None
18
Child 3 - Race/Ethnicity* This field is required.Please check all that apply. Hispanic Or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race
White
Hispanic Or Latino
Black or African American (Not Hispanic)
Native Hawaiian Or Pacific Islander
Native American
Multiracial
19
Child 3 - Primary Language* This field is required.
English
Spanish
20
Child 3 - Medical (Optional)Please list any medications, allergies or medical conditions that would prohibit or limit participation in any activities. If there are none please proceed to the next section.
Huge
Large
Normal
Small
Ok
Ok
21
Child 4 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
Gender
T Shirt Size
Address
City
IN
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
22
Child 4 - Academic Information
2019 / 2020 School Attended
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2019 / 2020 Grade Level
Yes
No
2019 / 2020 Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
23
Child 4 - Education Programs* This field is required.Is this child part of any of the following programs? If not please simply select "none" as your option.
Special Education
LEP
Gifted And Talented
None
24
Child 4 - Race/Ethnicity* This field is required.Please check all that apply. Hispanic Or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race
White
Hispanic Or Latino
Black or African American (Not Hispanic)
Native Hawaiian Or Pacific Islander
Native American
Multiracial
25
Child 4 - Primary Language* This field is required.
English
Spanish
26
Child 4 - Medical (Optional)Please list any medications, allergies or medical conditions that would prohibit or limit participation in any activities. If there are none please proceed to the next section.
Huge
Large
Normal
Small
Ok
Ok
27
Child 5 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
Gender
T Shirt Size
Address
City
IN
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
28
Child 5 - Academic Information
2019 / 2020 School Attended
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2019 / 2020 Grade Level
Yes
No
2019 / 2020 Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
29
Child 5 - Education Programs* This field is required.Is this child part of any of the following programs? If not please simply select "none" as your option.
Special Education
LEP
Gifted And Talented
None
30
Child 5 - Race/Ethnicity* This field is required.Please check all that apply. Hispanic Or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race
White
Hispanic Or Latino
Black or African American (Not Hispanic)
Native Hawaiian Or Pacific Islander
Native American
Multiracial
31
Child 5 - Primary Language* This field is required.
English
Spanish
32
Child 5 - Medical (Optional)Please list any medications, allergies or medical conditions that would prohibit or limit participation in any activities. If there are none please proceed to the next section.
Huge
Large
Normal
Small
Ok
Ok
33
Child 6 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
Gender
T Shirt Size
Address
City
IN
AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
MD
MA
MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
State
34
Child 6 - Academic Information
2019 / 2020 School Attended
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2019 / 2020 Grade Level
Yes
No
2019 / 2020 Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
35
Child 6 - Education Programs* This field is required.Is this child part of any of the following programs? If not please simply select "none" as your option.
Special Education
LEP
Gifted And Talented
None
36
Child 6 - Race/Ethnicity* This field is required.Please check all that apply. Hispanic Or Latino - a person of Cuban, Mexican, Puerto Rican, South or Central American or other Spanish culture or origin, regardless of race
White
Hispanic Or Latino
Black or African American (Not Hispanic)
Native Hawaiian Or Pacific Islander
Native American
Multiracial
37
Child 6 - Primary Language* This field is required.
English
Spanish
38
Child 6 - Medical (Optional)Please list any medications, allergies or medical conditions that would prohibit or limit participation in any activities. If there are none please proceed to the next section.
Huge
Large
Normal
Small
Ok
Ok
39
Primary Parent / GuardianYour Email is required in order for you to receive a confirmation of your submission.
Full Name
Relationship To Child
Full Address
Phone Number
Email Address
Yes
No
Lives with child(ren)
Yes
No
Authorized to pick up
40
Secondary Parent / Guardian (Optional)Your Email is required in order for you to receive a confirmation of your submission.
Full Name
Relationship To Child
Full Address
Phone Number
Email Address(Optional)
Yes
No
Lives with child(ren)
Yes
No
Authorized to pick up
41
Emergency Contact 1
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
Yes
No
Lives with child(ren)
Yes
No
Authorized to pick up
42
Emergency Contact 2 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
Yes
No
Lives with child(ren)
Yes
No
Authorized to pick up
43
Emergency Contact 3 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
Yes
No
Lives with child(ren)
Yes
No
Authorized to pick up
44
Authorized Adult 1 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
45
Authorized Adult 2 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
46
Authorized Adult 3 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
47
Date
Date
Year
Month
Day
10
1
2
3
4
5
6
7
8
9
10
11
12
Hour
13
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
Minutes
AM
AM
PM
48
Do you agree and understand the following terms? Please read carefully.If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County’s summer program, I agree to pay a $25.00 per child membership fee. This membership fee is non-refundable and runs through July 24, 2020. If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County’s summer program, I understand attendance of 3 days per week is required in order to maintain their space in the program. If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County’s summer program, I understand that they may not attend until I review and sign comprehensive waiver and release documents, including provisions related to the risks associated with the COVID-19 worldwide pandemic. If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County’s summer program, I give my consent to have my child(ren) photographed and allow the Club to publish any photographs, motion pictures, and/or recordings for any and all Club-related exhibitions, public displays, publications, and/or advertising purposes, without limitation or reservation. I also agree no compensation will be paid for any of the aforementioned
AgreeDecline
49
Please verify that you are human* This field is required.
Should be Empty:

Save your progress

Save your progress

Your form submission has been saved as a draft.

Save your progress

Your form submission has been saved as a draft.