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
2022/2023 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2022/2023 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 - Site Selection* This field is required.all sites operate afterschool until 6:00 PM daily
Brighton Street Club(all children in grades K-4)
Charles R. Westcott Club (all children in grades K-8)
Kesling Club (children in grades 5-8 who attend Kesling Intermediate School/La Porte Middle School)
Kingsford Heights Club (children in grades K-4 who attend Kingsford Heights Elementary School)
Lincoln Club (children in grades K-4 who attend Lincoln Elementary School)
Pine Club (children in grades K-6 who attend Pine Elementary School)
Springfield Club (children in grades K-6 who attend Springfield Elementary School)
Westville Club (children in grades K-8 who attend Westville Elementary/Middle Schools)
7
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.
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Large
Normal
Small
Ok
Ok
8
Do you need to register more than 1 child?* This field is required.
YESNO
9
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
10
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
11
Child 2 - Academic Information
2022/2023 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2022/2023 Grade Level
Yes
No
Past Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
12
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
13
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
14
Child 2 - Primary Language* This field is required.
English
Spanish
15
Child 2 - Site Selection* This field is required.all sites operate afterschool until 6:00 PM daily
Brighton Street Club(all children in grades K-4)
Charles R. Westcott Club (all children in grades K-8)
Kesling Club (children in grades 5-8 who attend Kesling Intermediate School/La Porte Middle School)
Kingsford Heights Club (children in grades K-4 who attend Kingsford Heights Elementary School)
Lincoln Club (children in grades K-4 who attend Lincoln Elementary School)
Pine Club (children in grades K-6 who attend Pine Elementary School)
Springfield Club (children in grades K-6 who attend Springfield Elementary School)
Westville Club (children in grades K-8 who attend Westville Elementary/Middle Schools)
16
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
17
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
18
Child 3 - Academic Information
2022/2023 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2022/2023 Grade Level
Yes
No
Past Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
19
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
20
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
21
Child 3 - Primary Language* This field is required.
English
Spanish
22
Child 3 - Site Selection* This field is required.all sites operate afterschool until 6:00 PM daily
Brighton Street Club(all children in grades K-4)
Charles R. Westcott Club (all children in grades K-8)
Kesling Club (children in grades 5-8 who attend Kesling Intermediate School/La Porte Middle School)
Kingsford Heights Club (children in grades K-4 who attend Kingsford Heights Elementary School)
Lincoln Club (children in grades K-4 who attend Lincoln Elementary School)
Pine Club (children in grades K-6 who attend Pine Elementary School)
Springfield Club (children in grades K-6 who attend Springfield Elementary School)
Westville Club (children in grades K-8 who attend Westville Elementary/Middle Schools)
23
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
24
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
25
Child 4 - Academic Information
2022/2023 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2022/2023 Grade Level
Yes
No
Past Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
26
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
27
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
28
Child 4 - Primary Language* This field is required.
English
Spanish
29
Child 4 - Site Selection* This field is required.all sites operate afterschool until 6:00 PM daily
Brighton Street Club(all children in grades K-4)
Charles R. Westcott Club (all children in grades K-8)
Kesling Club (children in grades 5-8 who attend Kesling Intermediate School/La Porte Middle School)
Kingsford Heights Club (children in grades K-4 who attend Kingsford Heights Elementary School)
Lincoln Club (children in grades K-4 who attend Lincoln Elementary School)
Pine Club (children in grades K-6 who attend Pine Elementary School)
Springfield Club (children in grades K-6 who attend Springfield Elementary School)
Westville Club (children in grades K-8 who attend Westville Elementary/Middle Schools)
30
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
31
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
32
Child 5 - Academic Information
2022/2023 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2022/2023 Grade Level
Yes
No
Past Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
33
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
34
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
35
Child 5 - Primary Language* This field is required.
English
Spanish
36
Child 5 - Site Selection* This field is required.all sites operate afterschool until 6:00 PM daily
Brighton Street Club(all children in grades K-4)
Charles R. Westcott Club (all children in grades K-8)
Kesling Club (children in grades 5-8 who attend Kesling Intermediate School/La Porte Middle School)
Kingsford Heights Club (children in grades K-4 who attend Kingsford Heights Elementary School)
Lincoln Club (children in grades K-4 who attend Lincoln Elementary School)
Pine Club (children in grades K-6 who attend Pine Elementary School)
Springfield Club (children in grades K-6 who attend Springfield Elementary School)
Westville Club (children in grades K-8 who attend Westville Elementary/Middle Schools)
37
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
38
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
39
Child 6 - Academic Information
2022/2023 School Enrolled At
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
2022/2023 Grade Level
Yes
No
Past Boys & Girls Club Member
Yes
No
Eligible For Free / Reduced Lunch?
40
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
41
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
42
Child 6 - Primary Language* This field is required.
English
Spanish
43
Child 6 - Site Selection* This field is required.all sites operate afterschool until 6:00 PM daily
Brighton Street Club(all children in grades K-4)
Charles R. Westcott Club (all children in grades K-8)
Kesling Club (children in grades 5-8 who attend Kesling Intermediate School/La Porte Middle School)
Kingsford Heights Club (children in grades K-4 who attend Kingsford Heights Elementary School)
Lincoln Club (children in grades K-4 who attend Lincoln Elementary School)
Pine Club (children in grades K-6 who attend Pine Elementary School)
Springfield Club (children in grades K-6 who attend Springfield Elementary School)
Westville Club (children in grades K-8 who attend Westville Elementary/Middle Schools)
44
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
45
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
46
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
47
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
48
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
49
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
50
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
51
Emergency Contact 1
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
Yes
No
Lives with child(ren)
52
Emergency Contact 2 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
Yes
No
Lives with child(ren)
53
Emergency Contact 3 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
Yes
No
Lives with child(ren)
54
Authorized Adult 1 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
55
Authorized Adult 2 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
56
Authorized Adult 3 (Optional)
Full Name
Relationship To Child
Full Address
Phone Number
Email Address (Optional)
57
Date
Date
Year
Month
Day
4
1
2
3
4
5
6
7
8
9
10
11
12
Hour
10
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
PM
AM
PM
58
Enrollment Terms* This field is required.I certify that am the parent/legal guardian of all minor children listed on this form. I understand that my child(ren)'s registration is not finalized and my children may not attend Club programming until I review and sign comprehensive waiver and release documents, including provisions related to the risks associated with the COVID-19 worldwide pandemic.
AgreeDecline
59
Attendance Requirement* This field is required.If my child(ren) is/are enrolled at a Boys & Girls Clubs of La Porte County site, I understand attendance an average of 3 days per week is required in order to maintain their space in the program.
AgreeDecline
60
Data Release* This field is required.If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County programming, I give my consent to have my child(ren) photographed and allow the Club and its collaborative partners 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
61
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 and/or the district in which they are enrolled.
AgreeDecline
62
Changes to Personal Information* This field is required.I understand and agree that any changes in my child(ren)'s authorized emergency contacts or individuals authorized for pick-up must be communicated to BGCLPC in writing to Karen Kintigh, Director of Operations, at kkintigh@bgclubmc.org. I also understand that BGCLP cannot deny a parent or legal guardian access to their child without proper documentation, and agree to provide BGCLPC with a copy of any relevant court order that may impact my child's program participation.
AgreeDecline
63
Please verify that you are human* This field is required.
Should be Empty: