Online Registration Form

Child's Name*

First Last

Birthday*

Grade*

Parent/Guardian Name*

Address*

Physical Address Mailing Address City State / Province / Region ZIP / Postal Code

Parent/Guardian Contact Number*

Parent/Guardian Email

Emergency/Medical Information

Please list emergency contacts in the event we cannot reach the parent/guardian listed above.

Emergency Contact #1, Name:*

Emergency Contact #1 Phone*

Emergency Contact #1 Relationship to youth

Emergency Contact #2, Name:*

Emergency Contact #2 Phone*

Emergency Contact #2 Relationship to youth

Any known allergies or serious health problems:

Does your child require medication(s)? If so, what medication(s) and how often? Please note, you may be required to administer all medications for your child. Speak to Collyn for more information.

In the event of an emergency does the BGC have permission to seek medical attention for your child?*

Yes
No

Program Information

Does the BGC have permission to use your child’s photo, work, and/or testimonial in public relations materials?*

Yes
No

The Boys & Girls Club of Menard offers a mentoring program where youth are matched with mentors to help youth: identify and achieve academic and personal goals, refrain from risky behaviors, and increase personal responsibility and confidence. Youth will participate in one or more of the following: Smart Moves, Passport to Manhood, Smart Girls, Torch Club, Keystone Club, Money Matters, & Goals for Graduation. Does your child/children have permission to participate in the Mentoring Program?*

Yes
No

Demographic Information (Confidential)

Please provide the following information. The information you provide in this section will be kept confidential and used for supplying demographics and applying for grants. The information is critical for our grant opportunities.

Household Income per year:

Does child live with

Mom
Dad
Step Mom
Step Dad
Grandparent
Other

Is there a member of the household 65 years or older?

Yes
No

Is there a member of the household who is handicapped?

Yes
No

Is this a single parent household?

Yes
No

Current head of household:

Male
Female

Current number in household:

Number in household under 18 years old:

Liability Release

I understand that my child will be participating in various activities and games at The Boys & Girls Club of Menard and I will not hold the BGC or any staff, volunteers, or affiliates responsible or liable for any accident or injury that may result.*

Yes
No

In the event of a field trip, my child IS allowed to be transported in a van or bus provided by BGC.*

Yes
No

I understand that BGC is considered an OPEN CAMPUS. Therefore, the BGC is NOT responsible for the manner in which my child arrives at or leaves this facility.*

Yes
No

I understand The BGC is NOT a licensed child-care facility*

Yes
No

I have read and agree to the rules and consequences in the parent handbook.*

Yes
No

Signature by typing full legal name.*

Tuition*

Email

This field is for validation purposes and should be left unchanged.

Boys & Girls Club Registration

Emergency/Medical Information

Program Information

Demographic Information (Confidential)

Liability Release

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