2022 BGC Tri-County Registration
This form is required for your child to participate in Club programming. Please take your time to complete the form in its entirety so that we have emergency contact information on file while your child is in our care. You must complete a separate registration form for each child you wish to enroll.

Boys & Girls Club of the Tri-County Area (BGC) Authorization: I understand the rules of BGC and I request that my child be admitted into membership. I have explained the rules to my child. I understand the hours of operation of BGC and that additional charges may be assessed if I pick up my child after these hours. I hereby give permission for the participant listed on this application to take part in BGC activities, which may include off-site events, academic assistance, continuing education and recreational programs. BGC may freely transport my child within the confines of the Berlin and/or Green Lake Area without further permission.

If a medical emergency arises, we will take all steps necessary to ensure the safety of the participant. If necessary, we will call a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. The participant is releasing the operator for any acts of negligence or its negligent acts. The participant assumes all risk associated with negligent acts of either the BGC or the participant. The participant cannot release willful, wanton, or intentional acts done with reckless disregard of the natural and probable consequence of injury. Additionally, I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately.

I give my consent to BGC to take the participant’s photograph during program activities, to be used for education, public relations and marketing purposes. I further give my consent to the school and BGC to share the participant’s student records with each other for purpose of providing educational support and assistance. In addition, I understand that the school district, BGC and CLC will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of Club programs on student achievement and to obtain continued funding for the program.
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Email *
Club Site *
BERLIN SITE ELEMENTARY AGE FAMILIES PLEASE READ! 21st Century Community Learning Center (Sparks Club) Acknowledgement
Boys & Girls Club of the Tri-County Area (BGC) & Sparks Club Community Learning Center (CLC) Authorization: I understand the rules of BGC and I request that my child be admitted into membership. I have explained the rules to my child. I understand the hours of operation of BGC and that additional charges may be assessed if I pick up my child after these hours. I hereby give permission for the participant listed on this application to take part in BGC and CLC activities, which may include off-site events, academic assistance, continuing education and recreational programs. BGC may freely transport my child within the confines of the Berlin Area School District without further permission. If a medical emergency arises, we will take all steps necessary to ensure the safety of the participant. If necessary, we will call a public emergency vehicle for transport to an emergency facility. I understand that I will be responsible for any transportation charges and medical expenses incurred. The participant is releasing the operator for any acts of negligence or its negligent acts. The participant assumes all risk associated with negligent acts of either the BGC or the participant. The participant cannot release willful, wanton, or intentional acts done with reckless disregard of the natural and probable consequence of injury. Additionally, I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately. I give my consent to BGC and CLC to take the participant’s photograph during program activities, to be used for education, public relations and marketing purposes. I further give my consent to the school, BGC and CLC to share the participant’s student records with each other for purpose of providing educational support and assistance. In addition, I understand that the school district, BGC and CLC will use participant records to evaluate individual progress and improvement, as well as to evaluate the impact of the program on student achievement and to obtain continued funding for the program. BGC and CLC require full participation in both: Academic Enrichment (Math & Literacy Activities) and Academic Support (Homework Help). While we will provide homework help, it will not be the main focus of our program. Please make sure to check with your child nightly to see if homework is competed. Divulging sensitive income information, such as free & reduced lunch status, is voluntary and will not affect whether a child will have access to programming.
 
My child is currently in elementary school and will be participating in the after-school Sparks Club program at the Berlin Site. I have read the above policies & procedures as they pertain to Sparks Club, a collaboration with the Berlin Area School District. *
I am registering my child for *
Child's First Name *
Child's Last Name *
Child's Home Address *
City, State, & Zip Code *
Child's Birth Date *
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Child's Age *
Child's Gender *
Child's Ethnicity *
Required
Child's Cell Phone Number *
Child's School (Spring 2022) *
Child's Grade (Fall 2021) *
Child's Email Address
Who does child live with? *
Total number of people in the home *
My child's first day of attendance will be
PRIMARY Parent/Guardian (First & Last Name) ALL parents/guardians listed are allowed to pick up the child unless access is prohibited or restricted by a court order. COURT ORDER must be provided to the Club. *
PRIMARY Parent/Guardian's Home Address *
City, State, Zip *
PRIMARY Parent/Guardian's Cell Phone Number *
PRIMARY Parent/Guardian's Email Address *
PRIMARY Parent/Guardian's Employer *
PRIMARY Parent/Guardian's Employer Phone Number *
OTHER Parent/Guardian (First & Last Name) ALL parents/guardians listed are allowed to pick up the child unless access is prohibited or restricted by a court order. COURT ORDER must be provided to the Club.
OTHER Parent/Guardian's Home Address
City, State, Zip
OTHER Parent/Guardian's Cell Phone Number
OTHER Parent/Guardian's Email Address
OTHER  Parent/Guardian's Employer
OTHER Parent/Guardian's Employer Phone Number
Is either parent/guardian registered with the military or live on a military base (Active, Retired, or Reserves)? *
Does your child, or someone in your household receive any of the following benefits? Check all that apply. *
Required
What is your total household income? This information is used for grant purposes only and will not be shared, nor names released.
Please list if your child has any allergies
Please list if your child has any medications they take
Please list any medical conditions staff should be aware of
Does your child have health insurance?
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Child's Physician's First & Last Name *
Address of medical facility your child receives care at *
Physician's Phone Number *
EMERGENCY CONTACT #1 (First & Last Name) -This person must be someone other than the parents/guardians who is allowed to pick up the child *
EMERGENCY CONTACT #1 Relationship to Child *
EMERGENCY CONTACT #1 Cell Phone Number *
EMERGENCY CONTACT #1 Alternative Phone Number (home or work) *
EMERGENCY CONTACT #2 (First & Last Name) -This person must be someone other than the parents/guardians who is allowed to pick up the child *
EMERGENCY CONTACT #2 Relationship to Child *
EMERGENCY CONTACT #2 Cell Phone Number *
EMERGENCY CONTACT #2 Alternative Phone Number (home or work) *
My child is eligible for Free/Reduced Lunch *
I hereby give my consent for emergency medical care or treatment to be used only if I cannot be reached immediately. *
My child may be photographed for marketing purposes including but not limited to; newspaper, newsletters, & social media. *
My child may be transported by the Club (ex. field trips). *
I give permission for my child to participate in walking field trips and other activities during operating hours. *
I give my permission for the Club to provide sunscreen and/or bug spray as needed, provided by the Club. *
I have been provided and had an opportunity to review the Club policies and procedures. *
I understand that it is my responsibility to update my contact information in writing to the Club if it changes. *
Please TYPE YOUR NAME BELOW if you agree that to the best of your knowledge this information is complete and accurate, and that you understand and are acknowledging submission of this information to the Boys & Girls Club of the Tri-County Area. *
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