Online Registration Coming Soon...

Summer Program Registration
Type of Registration:

Youth Information

Youth Name:
First Name
Middle Initial/Name
Last Name
Preferred Name:
/
/
Gender
School:
Grade:
Room Number:
Lives With
Check All That Apply
Ethnicity
Check All That Apply

Head of Household Information

Head of Household Name:
First Name
Last Name
Head of Household Gender
Home Address:
Country
Address Line 1
Address Line 2
City
State
Postal Code
Cell Phone:
Employer:
Work Phone Number:
Are Any Parents Active in the Military?
Are Any Parents Veterans?

Other Parent/ Guardian Information

Other Parent/ Guardian Name:
First Name
Last Name
Other Parent/ Guardian Gender
Cell Phone Number:
Employer:
Work Phone Number:

Youth Health Information

List Medical Problems, Disabilities, and Allergies:
List Medications Taken:

Pick Up Information

List the names and phone numbers of individuals, other than parents, authorized to pickup youth.
These individuals will also serve as emergency contacts if parent/ guardian cannot be reached.
Person(s) NOT Authorized to Pickup:

PARENT/GUARDIAN APPROVAL:  My child and I agree to follow the Club rules and policies, and we understand that Club membership is a privilege that may be revoked at any time.  Additional copies of policies are available upon request.

Internet:  I understand that my child will have supervised access to the Internet for web browsing and educational purposes.

Sharing of Personal Information:  I give my permission to the Boys & Girls Club of Kingsville to share information about the minor child listed on this application with Boys & Girls Clubs of America (BGCA) for research purposes and/or to evaluate program effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school district, and other information collected by Boys & Girls Club of Kingsville, including data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

Surveys and Questionnaires:  I give my permission to the Boys & Girls Club of Kingsville to survey my child about his or her Club experiences, risk behaviors, skills, and attitudes. I give consent for my child to complete youth outcomes surveys involving questions about his/her risk behaviors at the end of the calendar year, in the spring, and at the end of summer.  I am aware that blank sample copies of the youth outcomes surveys are available for review at the Front Desk.  I agree that if I do not want my child to participate in the youth outcomes surveys, I must provide notice in writing to the Boys & Girls Club of Kingsville.

School Information:  I give my permission to the Boys & Girls Club of Kingsville and my child’s school to exchange information regarding my child.  Information that will be shared may include the information provided on this membership application form, school records involving student progress, behavior, and attendance, and other information collected by Boys & Girls Club of Kingsville, including data collected via surveys or questionnaires. The purpose of this exchange is to help both organizations do a better job of helping the student be successful in school and in the Club.  This release is valid for one year and may be revoked by contacting my child’s school in writing.

Use of My Child’s Photos and Artwork:  I grant the Boys & Girls Club of Kingsville the irrevocable right to photograph / record my child along with any artwork or other projects created by my child and to use the said images in the production of promotional materials.  I relinquish all rights to copyright, title, property interest and/or any other interest in said images and I waive the right to inspection and approval of the finished reproduction.

Medical Treatment:  I give my permission for Club staff members to administer first aid treatment or allow a physician or hospital to administer emergency treatment to my child as deemed necessary. 

Release of Liability:  I will not hold the Boys & Girls Club of Kingsville responsible in case of any loss, damage, injury, or death resulting from use of Club facilities or participation in Club activities either at or away from the Club.

My child and I agree to follow the Club rules and policies.  I understand fees are non-refundable.

By Typing Your Name In The Box Provided You Constitue A Legal Signature Understanding And Affirming The Above Policies.
Date Submitted:
/
/
Notes for BGCK:
Entire Summer
Your total payment will be
Entire Summer Payment