YOUTH Summer 2023 Registration Form

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WE ARE FULL!* This field is required.If you chose to continue, please understand that your child will be added to the waitlist.
I understand
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Child's Name* This field is required.
First Name
Last Name
3
Grade Entering * This field is required.
Please Select
Please Select
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
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Date of Birth* This field is required.
5
Shirt Size * This field is required.
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Name* This field is required.
First Name
Last Name
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Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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Email* This field is required.
example@example.com
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Phone Number* This field is required.
Please enter a valid phone number.
10
Phone Number 2
Please enter a valid phone number.
11
Name
First Name
Last Name
12
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
13
Email
example@example.com
14
Phone Number
Please enter a valid phone number.
15
Phone Number 2
Please enter a valid phone number.
16
Name* This field is required.
First Name
Last Name
17
Relationship * This field is required.
18
Phone Number* This field is required.
Please enter a valid phone number.
19
Phone Number 2
Please enter a valid phone number.
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Name* This field is required.
First Name
Last Name
21
Relationship * This field is required.
22
Phone Number* This field is required.
Please enter a valid phone number.
23
Phone Number 2
Please enter a valid phone number.
24
Name* This field is required.
First Name
Last Name
25
Relationship * This field is required.
26
Phone Number* This field is required.
Please enter a valid phone number.
27
Phone Number 2
Please enter a valid phone number.
28
The sessions my child would like to attend: * This field is required.Check all that apply
Session 1 (July 3rd - July 14th)
Session 2 (July 17th - July 28th)
Session 3 (July 31st - August 11th)
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The days my child would like to attend: * This field is required.Check all that apply
Monday
Tuesday
Wednesday (optional)
Thursday
Friday
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Family Physician: * This field is required.
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Phone Number* This field is required.
Please enter a valid phone number.
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Special Conditions Medical Conditions, Allergies, Medication, Dietary Requirements, etc.
Huge
Large
Normal
Small
Ok
Ok
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By initialing below, I agree to notify the program of all of my child's medical conditions/needs.* This field is required.
ClearInitials
34
I also agree to authorize the Boys & Girls Club / Bangor School Department's 21st CCLC program to take the appropriate action to protect the well-being and safety of my child, including providing first aid, seeking emergency medical attention, or hospitalization should the need arise and I am unable to be reached.* This field is required.
Clear
35
Health Policy* This field is required.Parents/guardians are required to make an immediate pick-up for behavior problems, illness, lice or bathroom accidents. If the illness is contagious, a doctor’s note or approval from the Director will be required upon return.
ClearInitials
36
COVID-19 Policy* This field is required.Any children with any symptoms of COVID-19, including cough, fever, sore throat, fatigue, are prohibited from attending camp until their symptoms have 100% subsided. Children must be fever-free without the use of fever-reducing medication for at least 72 hours before returning to camp. If your child has been tested for COVID-19, they may not attend Club while awaiting test results and, if positive, obtain a physician’s note prior to returning.
ClearInitials
37
Photo ReleaseI give permission for the Boys & Girls Club / Bangor School Department’s 21st CCLC to use photos or videos taken of my child to advocate and/or publicize this program. These publications may be used in school or club newsletters, brochures, on their websites, television, or any other type of publication.
ClearInitials
38
Movies On occasion, movies may be shown due to inclement weather. For children in grades 1-5, only G-rated movies will be shown. By initialing here, I give permission for my child to watch movies during the Boys & Girls Club / Bangor School Department’s 21st CCLC Summer Program.
ClearInitials
39
21st CCLC Student Data* This field is required.Participation in 21st CCLC programs requires us to provide student information to the grant. The individual student information collected includes demographics, free and reduced lunch status, academic progress, and activity participation. All information collected is restricted and used solely for serving student needs and program evaluation purposes. By initialing, I authorize the release of my child’s information in order to provide evidence to maintain our 21st CCLC grant and to track overall student progress for program evaluation.
ClearInitials
40
Behavior Agreement * This field is required.The Boys & Girls Club reserves the right to issue lost privileges to avoid behaviors resulting in unsafe situations. Such behaviors may include verbal or physical aggression, vandalism, running away, hiding, and other actions that create disruptions of the camp day. In serious cases, we reserve the right to remove a child from camp for the day and to send him/her home, or remove him /her from camp altogether. By initialing, I indicate my understanding of the behavior agreement.
ClearInitials
41
Release of Liability * This field is required.By signing this form, I agree to hold harmless and indemnify the Bangor School System, Boys & Girls Club of Bangor, officers, agents, employees, volunteers, and contractors from all claims, demands, causes of action that arise from an unintentional or claimed negligent act or omission resulting from any student’s participation in the Boys & Girls Club / Bangor School Department’s 21st CCLC Program.
ClearInitials
42
Parent/Guardian Name: * This field is required.
First Name
Last Name
43
Parent/Guardian Signature:* This field is required.
ClearSignature
44
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