2025-2026 BGCGG Registration Form (High School)

BGCGG Registration Form

and Emergency Information
This program is made possible through a partnership between Garden Grove Unified School District and Boys & Girls Clubs of Garden Grove.
STUDENT NAME:
Name

First NameMiddle InitialLast Name
SIDN
Ethnicity:

Other
Gender:
Date of Birth:

MonthDayYear
Date
Age
Grade
School
Health Conditions/Allergies
My child has medical insurance:
Physician or Health Plan
Physician Phone Number
Format: (000) 000-0000.
PARENT/GUARDIAN #1:
Name

First NameMiddle InitialLast Name
Relationship to Student
Address

Street Address

Apartment

CityState / Province

Zip Code
E-mail Address
example@example.com
Date of Birth:

MonthDayYear
Date
Gender:
Home Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Ethnicity

Other
Primary Language

Other (Please indicate)
Household Income:
Household Size:
Who does the member live with?

Other
Are there any restraining orders or court orders we should be aware of? (* Copy of documents required)
I understand the policies of the ASSETs program are available at www.bgcgg.org and agree to comply.
To better address your student needs, please indicate if your child has an Individualized Education Program (IEP).
If Yes, do you grant BGCGG permission to obtain pertinent details of that IEP from GGUSD.
Photos or videos may be taken of my child and used for marketing and training purposes.
PARENT/GUARDIAN #2:
Name

First NameMiddle InitialLast Name
Relationship to Student
Address

Street Address

Apartment

CityState / Province

Zip Code
Home Phone Number
Format: (000) 000-0000.
Cell Phone Number
Format: (000) 000-0000.
Work Phone Number
Format: (000) 000-0000.
Emergency Contacts:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
I hereby consent to my child’s membership in the Boys & Girls Clubs of Garden Grove (BGCGG) and release the Club, Garden Grove Unified School District (GGUSD) and its agents from all liability. BGCGG has my permission to select a physician or contact emergency services in case of emergency and treatment may be given should the parent or authorized physician be unavailable.

BGCGG is committed to working collaboratively with parents/guardians around the needs of their students to ensure a child’s success in the program. When member behavior issues arise, BGCGG will work with parents and members to reach a resolution. Should BGCGG determine that my child cannot follow the established behavior policies, parents will be notified and disciplinary action will be taken, including possible termination of the child’s membership.

In order to evaluate the effectiveness of our program, my child may participate in assessment activities. I also consent to allow Boys & Girls Clubs of Garden Grove, to exchange confidential educational and health information and records regarding my child with Boys & Girls Clubs of America and GGUSD. I have read, understand and agree to the above activity.
Parent Signature
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

BGCGG Registration Form

STUDENT NAME:

PARENT/GUARDIAN #1:

PARENT/GUARDIAN #2:

Emergency Contacts: