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:

African AmericanAmerican IndianAsianCaucasianHispanic/LatinoMulti RacialPacific IslanderOther
Gender:

MaleFemaleNon-Binary
Date of Birth:*

MonthDayYear
Date
Age
Grade*
School*
Health Conditions/Allergies
My child has medical insurance:

YesNo
Physician or Health Plan
Physician Phone Number
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:

MaleFemaleNon-Binary
Home Phone Number*
Cell Phone Number
Work Phone Number
Ethnicity

African AmericanAmerican IndianAsianCaucasianHispanic/LatinoMulti RacialPacific IslanderOther
Primary Language

EnglishSpanishVietnameseKoreanOther (Please indicate)
Household Income:

$0-$24,999$25,000-$54,999$55,000-$89,999More than $90,000
Household Size:

2345678910
Who does the member live with?

Both ParentsSingle Parent HouseholdGuardianOther
Are there any restraining orders or court orders we should be aware of? (* Copy of documents required)

YesNo
I understand the policies of the ASSETs program are available at www.bgcgg.org and agree to comply.

YesNo
To better address your student needs, please indicate if your child has an Individualized Education Program (IEP).

YesNo
If Yes, do you grant BGCGG permission to obtain pertinent details of that IEP from GGUSD.

YesNo
Photos or videos may be taken of my child and used for marketing and training purposes.

YesNo
PARENT/GUARDIAN #2:
Name*

First NameMiddle InitialLast Name
Relationship to Student*
Address*

Street Address

Apartment

CityState / Province

Zip Code
Home Phone Number*
Cell Phone Number
Work Phone Number
Emergency Contacts:
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
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

Clear
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

BGCGG Registration Form

STUDENT NAME:

PARENT/GUARDIAN #1:

PARENT/GUARDIAN #2:

Emergency Contacts: