Boys & Girls Club Summer Registration Form

1
Child 1 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
2
Child 1 - Academic Information
School Attended for the Current (2024/25) School Year
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grade Level for the Current (2024/25) School Year
Please Select
Please Select
Yes
No
Past Member of Boys and Girls Club?
3
Child 1 - Site Selection* This field is required.
Charles R. Westcott Club (Michigan City)
Kesling Intermediate Campus (La Porte)
4
Do you need to register more than 1 child?* This field is required.
YESNO
5
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
6
Child 2 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
7
Child 2 - Academic Information
School Attended for the Current (2024/25) School Year
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grade Level for the Current (2024/25) School Year
Please Select
Please Select
Yes
No
Past Boys & Girls Club Member
8
Child 2 - Site Selection* This field is required.
Charles R. Westcott Club (Michigan City)
Kesling Intermediate Campus (La Porte)
9
Child 3 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
10
Child 3 - Academic Information
School Attended for the Current (2024/25) School Year
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grade Level for the Current (2024/25) School Year
Please Select
Please Select
Yes
No
Past Boys & Girls Club Member
11
Child 3 - Site Selection* This field is required.
Charles R. Westcott Club (Michigan City)
Kesling Intermediate Campus (La Porte)
12
Child 4 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
13
Child 4 - Academic Information
School Attended for the Current (2024/25) School Year
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grade Level for the Current (2024/25) School Year
Please Select
Please Select
Yes
No
Past Boys & Girls Club Member
14
Child 4 - Site Selection* This field is required.
Charles R. Westcott Club (Michigan City)
Kesling Intermediate Campus (La Porte)
15
Child 5 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
16
Child 5 - Academic Information
School Attended for the Current (2024/25) School Year
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grade Level for the Current (2024/25) School Year
Please Select
Please Select
Yes
No
Past Boys & Girls Club Member
17
Child 5 - Site Selection* This field is required.
Charles R. Westcott Club (Michigan City)
Kesling Intermediate Campus (La Porte)
18
Child 6 - Information* This field is required.
First Name
Last name
Date Of Birth (MM/DD/YYYY)
19
Child 6 - Academic Information
School Attended for the Current (2024/25) School Year
Please Select
Please Select
Kindergarten
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
Grade Level for the Current (2024/25) School Year
Please Select
Please Select
Yes
No
Past Boys & Girls Club Member
20
Child 6 - Site Selection* This field is required.
Charles R. Westcott Club (Michigan City)
Kesling Intermediate Campus (La Porte)
21
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
22
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
Row 0, Column 0
Springfield Club Extension
1
2
3
Row 1, Column 0
Westcott Club Extension
1
2
3
Row 2, Column 0
Pine Club Extension
Springfield Club Extension
Westcott Club Extension
Rank
1
2
3
Row 0, Column 0
Rank
1
2
3
Row 1, Column 0
Rank
1
2
3
Row 2, Column 0
1 of 3
23
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
24
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
Please Select
Please Select
Yes
No
Lives with child(ren)
Please Select
Please Select
Yes
No
Authorized to pick up
25
Are you able to commit to 80% attendance during the summer program?
YESNO
26
Date
Date
Year
Month
Day
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Hour
29
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Minutes
PM
AM
PM
27
Please verify that you are human* This field is required.
Should be Empty: