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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
Boys & Girls Club Registration Form
  • 1
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  • 2
    • Kindergarten
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    • Yes
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  • 3
    Is this child part of any of the following programs? If not please simply select "none" as your option.
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  • 4
    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
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  • 5
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  • 6
    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.
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  • 7
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  • 8
    Please select the amount of extra applicants that will have to be registered.
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  • 9
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    • NH
    • NJ
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  • 10
    • Kindergarten
    • 1st
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    • 3rd
    • 4th
    • 5th
    • 6th
    • 7th
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    • 10th
    • 11th
    • 12th
    • Yes
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    • Yes
    • No
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  • 11
    Is this child part of any of the following programs? If not please simply select "none" as your option.
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  • 12
    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
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  • 13
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  • 14
    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.
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  • 15
    IN
    • AL
    • AK
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    • 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
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    • SD
    • TN
    • TX
    • UT
    • VT
    • VA
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    • WI
    • WY
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  • 16
    • Kindergarten
    • 1st
    • 2nd
    • 3rd
    • 4th
    • 5th
    • 6th
    • 7th
    • 8th
    • 9th
    • 10th
    • 11th
    • 12th
    • Yes
    • No
    • Yes
    • No
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  • 17
    Is this child part of any of the following programs? If not please simply select "none" as your option.
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  • 18
    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
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  • 19
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  • 20
    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.
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  • 21
    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
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  • 22
    • Kindergarten
    • 1st
    • 2nd
    • 3rd
    • 4th
    • 5th
    • 6th
    • 7th
    • 8th
    • 9th
    • 10th
    • 11th
    • 12th
    • Yes
    • No
    • Yes
    • No
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  • 23
    Is this child part of any of the following programs? If not please simply select "none" as your option.
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  • 24
    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
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  • 25
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  • 26
    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.
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  • 27
    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
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    Enter
  • 28
    • Kindergarten
    • 1st
    • 2nd
    • 3rd
    • 4th
    • 5th
    • 6th
    • 7th
    • 8th
    • 9th
    • 10th
    • 11th
    • 12th
    • Yes
    • No
    • Yes
    • No
    Press
    Enter
  • 29
    Is this child part of any of the following programs? If not please simply select "none" as your option.
    Press
    Enter
  • 30
    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
    Press
    Enter
  • 31
    Press
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  • 32
    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.
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  • 33
    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
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    Enter
  • 34
    • Kindergarten
    • 1st
    • 2nd
    • 3rd
    • 4th
    • 5th
    • 6th
    • 7th
    • 8th
    • 9th
    • 10th
    • 11th
    • 12th
    • Yes
    • No
    • Yes
    • No
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    Enter
  • 35
    Is this child part of any of the following programs? If not please simply select "none" as your option.
    Press
    Enter
  • 36
    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
    Press
    Enter
  • 37
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  • 38
    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.
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  • 39
    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+
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  • 40
    • Pine Club Extension (Must attend Pine Elementary School)
    • Springfield Club Extension (Must attend Springfield Elementary School)
    • Westcott Club Extension
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  • 41
    Boys & 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.
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  • 42
    If 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?
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  • 43
    Your Email is required in order for you to receive a confirmation of your submission.
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  • 44
    Your Email is required in order for you to receive a confirmation of your submission.
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    • Yes
    • No
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    • Yes
    • No
    • Yes
    • No
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    • Yes
    • No
    • Yes
    • No
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    • Yes
    • No
    • Yes
    • No
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    Press
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    Press
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    AM
    • AM
    • PM
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  • 52
    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.
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  • 53
    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.
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  • 54
    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
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  • 55
    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.
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  • 56
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