Boys & Girls Club Program Week 8/10 - 8/14 7:30am - 5:00pm
Please fill out the form in its entirety. The fee will be $85 for the week, per child. Meals will NOT be provided this week. Please pack a breakfast, lunch, snack, and water bottle. We also ask that children wear closed toed shoes, no crocs or flip flops. Payment will be collected on Monday during drop off. We will accept credit/debit card payments ONLY. No cash, money orders, or checks will be accepted. For any questions, please contact kswoope@bgcofslc.org.
Please select the location you would like your child(ren) to attend:
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Ken Pruitt Boys & Girls Club (Lennard road & US1) 10673 SE Lennard Rd, Port St Lucie, FL 34952
Chuck Hill Boys & Girls Club (Prima Vista) 198 NW Marion Avenue, Port St. Lucie, FL 34983
Child's Full Name
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First Name
Last Name
Child's Date of Birth
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Month
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Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Home Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What grade is your child in?
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Parent or Guardian Name
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First Name
Last Name
Parent or Guardian Phone Number
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Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian Email Address
*
example@example.com
Emergency Contact Name
*
First Name
Last Name
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Please list any allergies or medical conditions that our team needs to be aware of. Write n/a if this portion does not pertain to your child.
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Parent/Guardian Signature
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Today's Date
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Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Register
Should be Empty: