Boys & Girls Clubs of the Virginia Peninsula

Yorktown Middle School Unit

11201 George Washington Highway, Yorktown, VA 23692 ♦ (757) 243-8307

REGISTRATION FORM

PLEASE COMPLETE BOTH FRONT AND BACK

Male ______Female ______(check one)

CHILD’S NAME: ______

FIRSTMIDDLE INITIALLASTNICKNAME

DATE OF BIRTH ______(if under 7, birth certificate required) AGE _____ PHONE: Home______

ADDRESS ______

STREET & NUMBER CITYZIP

FATHER/GUARDIAN’S NAME ______MOTHER/GUARDIAN’S NAME ______

FATHER/GUARDIAN’S EMPLOYMENT ______MOTHER/GUARDIAN’S EMPLOYMENT ______

FATHER/GUARDIAN’S PHONE: Work ______Cell ______MOTHER/GUARDIAN’S PHONE: Work ______Cell ______

EMAIL ADDRESS: ______

NAME AND ADDRESS OF TWO EMERGENCY CONTACTS IF A PARENT CANNOT BE REACHED:

  1. NAME ______ADDRESS ______PHONE ______
  1. NAME ______ADDRESS ______PHONE ______

SCHOOL ______GRADE ______ESTIMATED HIGH SCHOOL GRADUATION ______

Is the child eligible or receiving free lunch? ______YES ______NO Is the child eligible or receiving reduced lunch? ______YES ______NO

Is either parent/guardian serving in the U.S. Military? If yes, what branch ______

LIST CHRONIC PHYSICAL PROBLEMS AND DEVELOPMENTAL DELAYS, IF ANY: ______

______

AGREEMENT BETWEEN PARENT AND BOYS & GIRLS CLUBS OF THE VIRGINIA PENINSULA

  1. I hereby give my authorization to the Boys & Girls Clubs of the Virginia Peninsula, hereafter referred to as Club, to provide for emergency medical care when I cannot be located immediately.
  2. The Clubwill notify me when my child becomes ill and I will arrange to have my child picked up as soon as possible.
  3. If the Club decides to terminate the enrollment of my child, they will provide to me in writing the reason(s) for termination.
  4. I understand that it is the Club’s desire that members stay in the building, even though they are free to enter and leave the premises without permission or supervision. I will instruct my child as to whether or not they may leave the Club.
  5. I hereby give my permission to the Club to photograph/videotape my child for public relations and/or educational purposes. Furthermore, it is understood that my child may be included in programs or news stories that are released to the local media.
  6. I hereby give my permission to the Club to collect information from my child's school regarding their grades and any other relevant information.
  7. I give permission to the Club to collect information about their club experience via online or written surveys, questionnaires, interviews, and focus groups from the minor listed on this application. Any and all information received will be kept strictly confidential. The results will be shared with Club staff, Boys & Girls Clubs of America (BGCA), funders and other community stakeholders to evidence program effectiveness and/or club impact on our members.

______

SIGNATURE OF PARENT OR GUARDIANDATE

______

**FOR UNIT DIRECTOR USE ONLY – DO NOT WRITE IN THIS SPACE**

DATE JOINED ______FEE PAID ______CLASS ______CLUB # ______REG. BY ______

BOYS & GIRLS CLUBS OF THE VIRGINIA PENINSULA

Please complete the following demographics information for your child. This information is required for our Federal Funding Reporting Requirements and will be tabulated with all other data received. Your personal information will be kept strictly confidential.

Single-parent Family: ____yes____no

Who does the child live with?______# of brothers ______# of sisters ______

Race/Ethnicity: (circle appropriate race/ethnicity)

Asian  / Asian/Pacific Islander 
Asian & White  / American Indian/Alaskan Native 
Black/African American  / American Indian/Alaskan Native & Black 
Black/African American & White  / American Indian/Alaskan Native & White 
Hispanic  / Native Hawaiian/Other Pacific Islander 
White  / Other Multi-Racial  ______

Family Size: Number in Household (circle appropriate number)

Two  Three  Four  Five  Six  Seven  Eight  Nine  Ten 

Household Income: (circle appropriate income)

$0 – 18,090 $18,091 – 24,360 $24,361- 30,630 $30,631 – 36,900 

$36,901- 43,170 $43,171 – 49,440 $49,441 – 55,710 $55,711 – 61,980 

$61,981 and up 

I confirm the above is true and correct.

______

Parent Signature

ALL OF THE ABOVE INFORMATION WILL BE KEPT STRICTLY CONFIDENTIAL.