Before & Afterschool 2024-2025

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Youth After-School Program (K - 5th grade)
Teen After-School Program (6th - 8th grade)
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Name* This field is required.
First Name
Last Name
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Date of Birth* This field is required.
Date
Month
Day
Year
4
Address* This field is required.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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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Phone Number* This field is required.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.
Please enter a valid phone number.
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Race/Nationality* This field is required.
African-American
Native American
Asian
Hispanic
White
Multi-Racial
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Primary language spoken at home* This field is required.
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Grade entering fall 2024* This field is required.
K
1
2
3
4
5
6
7
8
9
School* This field is required.
10
Are there any physical, mental, or behavioral health conditions we should be aware of? If yes, please explain.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
11
Does the member have any allergies? If yes, please list.* This field is required.
Huge
Large
Normal
Small
Ok
Ok
12
Dietary restrictions
13
Activity restrictions
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Lives with (check all that apply)* This field is required.
Mother only
Father only
Both parents
shared/joint custody
Grandparents
Other relatives
Foster parents
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Is the member a U.S. citizen?* This field is required.
Yes
No
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Name of Parent/Caregiver/Legal Guardian* This field is required.
First Name
Last Name
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Relation to Member* This field is required.
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Phone Number* This field is required.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.
Please enter a valid phone number.
19
Phone Number #2By 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.
Please enter a valid phone number.
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Email* This field is required.
example@example.com
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Is this parent/guardian currently working or in school?* This field is required.
Yes
No
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Name of 2nd Parent/Caregiver (if applicable)
First Name
Last Name
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Relation to Member
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Phone NumberBy 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.
Please enter a valid phone number.
25
Email
example@example.com
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Is this parent/guardian currently working or in school?
Yes
No
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Authorized Pick-Up Name (other than parents)* This field is required.
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Relation to Member* This field is required.
29
Phone Number* This field is required.
Please enter a valid phone number.
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Authorized Pick-Up Name #2 (other than parents)
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Relation to Member
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Phone Number
Please enter a valid phone number.
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How many people are in the Member's Household?* This field is required.
34
Which of the following state programs benefit the member's household?* This field is required.
SSDI
SNAP
SSI
TANF
Free/Reduced School Lunch
Child Care Subsidy
None
Other
35
Household Income* This field is required.
Under $30,000
$30,001-$40,000
$40,001-$50,000
$50,001-$60,000
$60,001-$70,000
$70,001-$80,000
$80,001-$90,000
$90,001+
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Is either parent/caregiver in the military/National Guard?* This field is required.
Yes
No
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Emergency Action* This field is required.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.
Clear
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Photo Release* This field is required.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.
Clear
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Bangor School Department* This field is required. I agree to an exchange of information between the Boys & Girls Club of Bangor and school personnel whenever it would be beneficial to my child. I also authorize the Bangor School Department to release data pertaining to my child, including standard test scores, grades, and attendance, with the knowledge that this will be used to track overall student progress for program evaluation purposes.
Clear
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Transportation* This field is required.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.
Clear
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Field Trips* This field is required.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.
Clear
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Behavior Agreement* This field is required.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.
Clear
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Surveys/Questionnaires* This field is required.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.
Clear
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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.* This field is required.
Clear
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