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TEEN SCENE - Registration
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1
Name:
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First Name
Last Name
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2
Grade:
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9th - Freshman
10th - Sophomore
11th - Junior
12th - Senior
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3
Date of Birth:
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Date
Year
Month
Day
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4
Address
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Street Address
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City
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Postal / Zip Code
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Afghanistan
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Portugal
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Rwanda
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Saint Helena
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eSwatini
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Switzerland
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Taiwan
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Tanzania
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Tokelau
Tonga
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Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
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United Kingdom
United States
Uruguay
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US Virgin Islands
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Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
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
United States
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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5
Member Phone Number
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Area Code
Phone Number
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6
Does the member have any allergies:
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YES
NO
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7
If yes, please list:
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8
Name
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First Name
Last Name
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9
Phone Number
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By clicking "Submit " I agree to receive emails, text messages, and phone calls. Consent is not a condition of purchase. Msg & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP.
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10
Email
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example@example.com
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11
Name
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12
Phone Number
By clicking "Submit " I agree to receive emails, text messages, and phone calls. Consent is not a condition of purchase. Msg & data rates may apply. Message frequency varies. Unsubscribe at any time by replying STOP.
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13
Email
example@example.com
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14
Name
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First Name
Last Name
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15
Phone Number
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16
Email
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example@example.com
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17
Emergency Action
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I authorize the Boys & Girls Club of Bangor 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. I understand that I am responsible for payment of any medical attention and treatment, including emergency transportation.
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18
Photo Release
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I give the Boys & Girls Club of Bangor permission to use photos or videos taken of my child for public relations purposes These photos may be used in club newsletters, brochures, on the Club's website, television, social media or other types of publication.
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19
Transportation
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I understand that I am responsible for providing transportation home from the Boys & Girls Club of Bangor. If this is not possible, I understand that I am responsible for contacting the Club to make other arrangements.
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20
Field Trips
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I give permission for my child to take part in field trips and excursions under proper supervision by the Boys & Girls Club of Bangor. It is my understanding that I will be notified when such trips are planned, and participation will be subject to the member's ability to follow club guidelines and demonstrate safe and responsible behavior.
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21
Behavior Agreement
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The Boys & Girls Club of Bangor 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 serious disruptions to the program. The Club reserves the right to send members home for the day or remove them from the program altogether. By initialing, I indicate my understanding of the behavior agreement.
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22
Surveys/Questionnaires
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I give permission for the Boys & Girls Club of Bangor to survey my child about his/her/their Club experience and behaviors, skills, and attitudes using BGCA's National Youth Outcomes Indicator, and/or other periodic surveys used to track the well-being of our members. All surveys will protect members' privacy.
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23
Walker Release
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I hereby certify that my child has permission to ride their bike and/or walk to and from the Boys & Girls Club of Bangor Clubhouse and/or Gym by themselves. In doing so the Boys & Girls Club of Bangor is not responsible for his/ her actions, safety, or supervision on their way to and from the Club. Immediately upon their arrival and just prior to dismissal, they will check in/out with a staff member. I understand that if my child does not sign himself in or out, or any other issues arise, the Club reserves the right to deny permission for the child to walk and/or ride to and from Club. I agree and do hereby waive and release all claims against the Boys and Girls Club of Bangor, and any of its employees and agree to hold harmless from any and all liability relating to my child for any personal injury or illness that may be suffered or any loss of property that may occur to my child that is not due to negligence by a Boys and Girls Club representative (i.e. employee or chaperone).
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24
Release of Liability
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I, the parent/guardian of the minor child listed on this registration form, for ourselves, our heirs, executors and administrators, hereby release, waive, acquit and forever discharge the Boys & Girls Club of Bangor, and Boys & Girls Clubs of America, their representatives, successors, insurers, assigns or any other person or entity associated with any of the above organization, such as staff, directors or volunteers, from all liability, claims, demands, or causes of action for any and all loss, damage, injury and any claim of damages resulting from use of facilities owned or controlled by the above organization, or participation in activities of said organizations either at or away from the Club.
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