Boys & Girls Club Summer 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

State

2

Child 1 - Academic Information

School as of April 30, 2024

Grade Level as of April 30, 2024

Past Boys & Girls Club Member

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

Other

5

Child 1 - Primary Language* This field is required.

English

Spanish

Other

6

Child 1 - Site Selection* This field is required.Both sites operate from 7:45 AM to 4:30 PM daily and are open to children who were in kindergarten through 8th grade during the 2023/2024 school year.

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.

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.

10

Child 2 - Information* This field is required.

First Name

Last name

Date Of Birth (MM/DD/YYYY)

Gender

T Shirt Size

Address

City

State

11

Child 2 - Academic Information

School as of April 30, 2024

Grade Level as of April 30, 2024

Past Boys & Girls Club Member

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

Other

14

Child 2 - Primary Language* This field is required.

English

Spanish

Other

15

Child 2 - Site Selection* This field is required.Both sites operate from 7:45 AM to 4:30 PM daily and are open to children who were in kindergarten through 8th grade during the 2023/2024 school year.

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.

17

Child 3 - Information* This field is required.

First Name

Last name

Date Of Birth (MM/DD/YYYY)

Gender

T Shirt Size

Address

City

State

18

Child 3 - Academic Information

School as of April 30, 2024

Grade Level as of April 30, 2024

Past Boys & Girls Club Member

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

Other

21

Child 3 - Primary Language* This field is required.

English

Spanish

Other

22

Child 3 - Site Selection* This field is required.Both sites operate from 7:45 AM to 4:30 PM daily and are open to children who were in kindergarten through 8th grade during the 2023/2024 school year.

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.

24

Child 4 - Information* This field is required.

First Name

Last name

Date Of Birth (MM/DD/YYYY)

Gender

T Shirt Size

Address

City

State

25

Child 4 - Academic Information

School as of April 30, 2024

Grade Level as of April 30, 2024

Past Boys & Girls Club Member

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

Other

28

Child 4 - Primary Language* This field is required.

English

Spanish

Other

29

Child 4 - Site Selection* This field is required.Both sites operate from 7:45 AM to 4:30 PM daily and are open to children who were in kindergarten through 8th grade during the 2023/2024 school year.

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.

31

Child 5 - Information* This field is required.

First Name

Last name

Date Of Birth (MM/DD/YYYY)

Gender

T Shirt Size

Address

City

State

32

Child 5 - Academic Information

School as of April 30, 2024

Grade Level as of April 30, 2024

Past Boys & Girls Club Member

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

Other

35

Child 5 - Primary Language* This field is required.

English

Spanish

Other

36

Child 5 - Site Selection* This field is required.Both sites operate from 7:45 AM to 4:30 PM daily and are open to children who were in kindergarten through 8th grade during the 2023/2024 school year.

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.

38

Child 6 - Information* This field is required.

First Name

Last name

Date Of Birth (MM/DD/YYYY)

Gender

T Shirt Size

Address

City

State

39

Child 6 - Academic Information

School as of April 30, 2024

Grade Level as of April 30, 2024

Past Boys & Girls Club Member

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

Other

42

Child 6 - Primary Language* This field is required.

English

Spanish

Other

43

Child 6 - Site Selection* This field is required.Both sites operate from 7:45 AM to 4:30 PM daily and are open to children who were in kindergarten through 8th grade during the 2023/2024 school year.

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.

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:

46

Club Selection* This field is required.

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

Springfield Club Extension

Westcott Club Extension

Pine Club Extension

Springfield Club Extension

Westcott Club Extension

Rank

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

Lives with child(ren)

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)

Lives with child(ren)

Authorized to pick up

51

Emergency Contact 1

Full Name

Relationship To Child

Full Address

Phone Number

Email Address (Optional)

Lives with child(ren)

52

Emergency Contact 2 (Optional)

Full Name

Relationship To Child

Full Address

Phone Number

Email Address (Optional)

Lives with child(ren)

53

Emergency Contact 3 (Optional)

Full Name

Relationship To Child

Full Address

Phone Number

Email Address (Optional)

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

Hour

Minutes

58

Enrollment Terms* This field is required.I certify that I am the parent/legal guardian of all minor children listed on this form. I understand that I will be receiving additional paperwork related to my children's participation in club programming that I must review, sign and return.

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. I understand and agree that if my child is selected as Member of the Month or another special award, they may be recognized individually on BGCLPC's social media channels.

AgreeDecline

61

Privacy Policy* This field is required.If my child(ren) is/are enrolled in Boys & Girls Clubs of La Porte County, I understand that information related to their enrollment and participation may be shared with the district where the Club facility is located 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 summerregistration@bgclubmc.org. I also understand that BGCLPC 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.