Boys & Girls Club Registration Form

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2020 Boys & Girls Club of La Porte County

2020 Boys & Girls Club of La Porte County

School Year Registration Form

52Questions

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
2020/2021 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2020/2021 Grade Level
Yes
No
Past 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
2020/2021 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2020/2021 Grade Level
Yes
No
Past 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
2020/2021 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2020/2021 Grade Level
Yes
No
Past 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
2020/2021 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2020/2021 Grade Level
Yes
No
Past 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
2020/2021 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2020/2021 Grade Level
Yes
No
Past 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
2020/2021 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2020/2021 Grade Level
Yes
No
Past 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
Annual Household Income* This field is required.We are asked to provide this information as a condition of some of the grants we receive. Thank you for your assistance! Please select the category that best describes your annual household income:
No Category Selected
No Category Selected
Under $10,000
$10,000—$19,999
$20,000—$29,000
$30,000—$39,999
$40,000—$49,999
$50,000—$99,999
$100,000+
Prefer not to answer
40
Club Selection* This field is required.
Pine Club Extension (Must attend Pine Elementary School)
Springfield Club Extension (Must attend Springfield Elementary School)
Westcott Club Extension
41
Daytime Club AttendanceBoys & Girls Clubs of La Porte County will be providing daytime programming from 7:30 AM to 4:00 PM, with extended afterschool care at the Charles R. Westcott Club only. Please rank these sites in order of preference.
Rank
Pine Club Extension
1
2
3
Springfield Club Extension
1
2
3
Westcott Club Extension
1
2
3
Pine Club Extension
Springfield Club Extension
Westcott Club Extension
Rank
1
2
3
Rank
1
2
3
Rank
1
2
3
1 of 3
42
After school Club AttendanceIf you ranked the Charles R. Westcott Club as your first choice, would you like to have your child attend the afterschool program beginning at 4:00 PM?
YESNO
43
Primary Parent / Guardian* This field is required.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
Yes
No
Lives with child(ren)
Yes
No
Authorized to pick up
44
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
45
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
46
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
47
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
48
Authorized Adult 1 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
49
Authorized Adult 2 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
50
Authorized Adult 3 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
51
Date
Date
Year
Month
Day
12
1
2
3
4
5
6
7
8
9
10
11
12
Hour
50
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
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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
52
Enrollment Terms* This field is required.I understand that my child(ren)'s registration is not finalized and my children may not attend Club until I review and sign comprehensive waiver and release documents, including provisions related to the risks associated with the COVID-19 worldwide pandemic.
AgreeDecline
53
Attendance Requirement* This field is required.If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County’s school year program, I understand attendance of 3 days per week is required in order to maintain their space in the program.
AgreeDecline
54
Data Release* This field is required.If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County’s school year 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
55
Privacy Policy* This field is required.If my child(ren) is enrolled in Boys & Girls Clubs of La Porte County, I understand that information related to their enrollment and participation may be shared with Michigan City Area Schools or the district in which they are enrolled.
AgreeDecline
56
Please verify that you are human* This field is required.
Should be Empty:

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