2025/2026 After School & Teen Program Registration
Student's Information
Member's Name
*
First Name
Last Name
Member's Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Member's Birth Date
*
Please select a month
January
February
March
April
May
June
July
August
September
October
November
December
Month
Please select a day
1
2
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4
5
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25
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31
Day
Please select a year
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
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1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Year
School Name
*
IAA (Integrated Arts Academy)
EMS (Edmunds Middle School)
HMS (Hunt Middle School)
BHS (Burlington High School)
Other
Grade entering in September 2025
*
Please Select
0-Kindergarten (IAA)
1st Grade (IAA)
2nd Grade (IAA)
3rd Grade (IAA)
4th Grade (Club)
5th Grade (Club)
6th Grade (Club)
7th Grade (Club)
8th Grade (Club)
-8th Grade (Teen Program)
-9th Grade (Teen Program)
-10th Grade (Teen Program)
-11th Grade (Teen Program)
-12th Grade (Teen Program)
Grades Kindergarten through 3rd are currently FULL. If you would like to add your child to the WAITLIST, please select "Yes" and continue completing this registration.
*
Yes
No
Member's Email
*
example@example.com
School Name:
*
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Parent / Guardian Information
Parent/Guardian Name (1)
*
First Name
Last Name
Relationship to Member
*
Cell Phone Number
Home Phone Number
Work Number
Email
*
example@example.com
Is parent/guardian's address different than member's?
*
Yes
No
Address (if different than member)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian Name (2)
First Name
Last Name
Relationship to Member
Cell Phone Number
Home Phone Number
Work Number
Email
example@example.com
Is parent/guardian's address different than member's?
Yes
No
Address (if different than member)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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Emergency & Medical Information
Emergency Contact (1)
*
First Name
Last Name
Relationship to Member
*
Phone Number
*
Alternate Phone Number
Permission to Pick-Up
*
Yes
No
Emergency Contact (2)
First Name
Last Name
Relationship to Member
Phone Number
Alternate Phone Number
Permission to Pick-Up
Yes
No
Allergies or Dietary Requirements
*
N/A
Click to enter Allergies or Dietary Requirements
Current Medications
*
N/A
Click to enter any medications we should be aware of.
Child's Doctor
*
Doctor's Phone Number
*
Child's Dentist
*
Dentist's Phone Number
*
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Permissions
(1)This person has permission to pick up on any given day:
First Name
Last Name
(1)Phone Number
Please enter a valid phone number.
(2)This person has permission to pick up on any given day:
First Name
Last Name
(2)Phone Number
Please enter a valid phone number.
(3)This person has permission to pick up on any given day:
First Name
Last Name
(3)Phone Number
Please enter a valid phone number.
This person DOES NOT have permission to pick up:
First Name
Last Name
This person DOES NOT have permission to pick up:
First Name
Last Name
What days of the week do you expect your child to attend afterschool? (please select all that apply)
*
Monday
Tuesday
Wednesday
Thursday
Friday
My child may walk home at 5:30pm:
*
Yes
No
My child may use the internet/ electronics for academics and age appropriate activities:
*
Yes
No
My child may watch movies/videos/tv rated up to:
*
G
PG
PG-13
R
My child may go on field trips whether by foot, van,or other contracted transportation:
*
Yes
No
BGC is allowed to contact/speak with my child's school regarding their development, behavior & education:
*
Yes
No
BGC is allowed to take photographs/video for use by the Boys & Girls Club:
*
Yes
No
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Demographics
As a non-profit we rely on outside funding sources to continue to offer our services at such a low cost (in some cases, at no cost). The information collected in the section below is required to secure that funding. This information is never reported with you/your child’s name. This information is strictly confidential and does not in any way affect eligibility for Club programming.
Child's Name
First Name
Last Name
Gender
Number of people living in household
Member's of household receive the following services
Food Stamps
Free/Reduced Lunch
General Assistance
Unemployment
TANF
Ethnicity (choose the one that BEST applies)
American Indian/Alaska Native
Asian
Black or African American
Hispanic, Latino, Spanish Origin
Native Hawaiian/Pacific Island
White
Mixed Ethnicity
Other
Unknown
Household Income
$0-$15,000
$15,001-$30,000
$30,001-$45,000
$45,001-$60,000
$60, 001-$75,000
$75,001 and up
Is a parent/guardian currently incarcerated?
Yes
No
Is a parent/guardian an active member of the military?
Yes
No
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Afterschool Fees:
We DO NOT require a fee for our After School Programs. In order for us to keep our programming this way, we do REQUIRE families to complete the CCFAA. See below.
Child Care Financial Aid Application (CCFAA):
You can get an application at both the Main Clubhouse and our IAA Site. You can also find a printable version on our website under the Summer Camp section. If you would like assistance completing the CCFAA, please feel free to reach out to the Club and we would be happy to assist!
Do you receive Reach Up?
*
Yes
No
Teen Agreement
I give permission for the Boys and Girls Club to access the participant’s immunization records. In case of emergency, the Boys and Girls Club Staff has my permission to give first aid or take the participant to a hospital for treatment and call a doctor for medical or surgical care. Should an emergency arise, I understand that a conscientious effort will be made to locate the participant’s guardians or an emergency contact before any action is taken, but I understand any expenses associated with such emergency is the responsibility of the participant, if it is not possible to locate the participant’s guardians in advance of treatment. I hereby, for myself, my child, my heirs, executors and administrators waiver and release any and all rights and claims for damages I or my child may have against the Boys and Girls Club of Burlington for any and all injuries suffered during any activity sponsored by these listed organizations. I understand that any and all use of technology at the Club is subject to be monitored and is restricted to appropriate use.
Teen Participant
*
First Name
Last Name
Family Agreement
I understand my child will not be able to leave the Club for any reason without written permission or phone call from a parent/guardian. I give the Boys and Girls Club of Burlington permission to Survey my child for use in reports and general knowledge. I give permission for the Boys and Girls Club to access and report my child’s immunization records. In case of emergency, the Boys and Girls Club Staff has my permission to give first aid or take the participant to a hospital for treatment and call a doctor for medical or surgical care for my child. Should an emergency arise, I understand that a conscientious effort will be made to locate me or an emergency contact before any action is taken, but I agree to accept any expenses associated with such emergency if it is not possible to locate me in advance of treatment. I hereby, for myself, my child, my heirs, executors and administrators waiver and release any and all rights and claims for damages I or my child may have against the Boys and Girls Club of Burlington for any and all injuries suffered by my child at any activity sponsored by these listed organizations. I have been informed that the Boys & Girls Club of Burlington has a freedom of access policy and complaint procedures concerning the welfare of children outlined in the Family Handbook.
Boys & Girls Club 23/24 After School Family & Member Handbook
*
Parent/Guardian
*
First Name
Last Name
Today's Date
*
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Month
-
Day
Year
Date
Submit
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