Teen Center School Year Program Registration

How many children will you be registering?*
- 1
- 2
- 3

Please list the names of the children you are registering*
First Name Last Name

Parent/Guardian #1
First and Last Name*
First Last
Home Address*
Street Address Address Line 2 City State ZIP Code
Email*
Cell Phone*
Would you like to receive text message communication to this phone number?*
- Yes
- No
Employer*
Work Phone
Are you active in the Armed Forces?*
- Yes
- No
Parent/Guardian #2
First and Last Name
First Last
Home Address
Same as Parent/Guardian #1

Street Address Address Line 2 City State ZIP Code
Email
Cell Phone
Would you like to receive text message communication to this phone number?
- Yes
- No
Employer
Work Phone
Are you active in the Armed Forces?
- Yes
- No

Are you in need of financial assistance?*
Membership fees are a one-time payment and cover the full school year program September - May. Financial assistance options available for qualifying members. All fees are due at time of registration.
- I can pay the full amount of $60
- Yes, I will need the discounted rate of $30
- I would like to set up a payment plan, please contact me
Please share your exact yearly household income:
Please list your family’s exact yearly household income.

Child #1 Information
First and Last Name*
First Last
Child's Birth Date*
Month
Day
Year
Child's Gender*
Child's Ethnicity*
Child Lives With*
Child's School Attending*
2024-25 Grade*
Child 1 Cost
Please List any Medical Conditions your Child May Have
Please list any Medications Your Child Takes
Does your child qualify for free or reduced lunch?*
- Yes
- No
Do you give your child permissions to leave on their own?*
- Yes, anytime
- Yes, after ________________
- My child has a YMCA membership and can sign out to go to the Y
- No
After what time is your child allowed to leave?*

: Hours

Minutes

AM/PM
Child #1 Media permission
- Please check here if you DO NOT want your child to appear in any media coverage for the Boys & Girls Club of Fond du Lac

Child #2 Information
First and Last Name*
First Last
Child's Birth Date*
Month
Day
Year
Child's Gender*
Child's Ethnicity*
Child Lives With*
Child's School Attending*
2024-25 Grade*
Child #2 Cost
Please List any Medical Conditions your Child May Have
Please list any Medications Your Child Takes
Does your child qualify for free or reduced lunch?*
- Yes
- No
Do you give your child permissions to leave on their own?*
- Yes, anytime
- Yes, after ________________
- My child has a YMCA membership and can sign out and go to the Y
- No
After what time is your child allowed to leave?*

: Hours

Minutes

AM/PM
Child #2 Media permission
- Please check here if you DO NOT want your child to appear in any media coverage for the Boys & Girls Club of Fond du Lac

Child #3 Information
First and Last Name*
First Last
Child's Birth Date*
Month
Day
Year
Child's Gender*
Child's Ethnicity*
Child Lives With*
Child's School Attending*
2024-25 Grade*
Child #3 Cost
Please List any Medical Conditions your Child May Have
Please list any Medications Your Child Takes
Does your child qualify for free or reduced lunch?*
- Yes
- No
Do you give your child permissions to leave on their own?*
- Yes, anytime
- Yes, after ________________
- My child has a YMCA membership and can sign out to go to the Y
- No
After what time is your child allowed to leave?*

: Hours

Minutes

AM/PM
Child #3 Media permission
- Please check here if you DO NOT want your child to appear in any media coverage for the Boys & Girls Club of Fond du Lac

Emergency Contacts / Pick Up Information
Non Parent/Guardian #1 Emergency Contact
Name*
First Last
Home/Cell Phone*
Relationship to Child*
Non Parent/Guardian #2 Emergency Contact
Name*
First Last
Home/Cell Phone*
Relationship to Child*
Non Parent/Guardian #3 Emergency Contact
Name
First Last
Home/Cell Phone
Relationship to Child
Please list any other individuals that are allowed to pick up
First Name Last Name
Late pickup agreement*
By checking the box, I understand that if my child is not picked up by 7:00pm, I will be charged a $5.00 fee. I also understand that if club staff are unable to contact a caregiver within 30 minutes of the end of Club programming, law enforcement and Child Protective Services may be notified.
Agree*

Signature and Agreement
Please Read Carefully

Behavior Support & Expectations

I have read and understand the Boys & Girls Club of Fond du Lac’s PBIS Expectations and Behavior Support Plan. I understand that all members are expected to follow these policies at all times when they are part of Boys & Girls Club activities. I understand the club reserves the right to search all personal belongings. Read the PBIS Expectations and Behavior Support here.

Medical Emergency

In the event of an emergency I understand that every attempt will be made to contact me. If I cannot be reached I hereby give my permission to the physician selected by the Boys & Girls Club staff member to secure proper treatment for my child.

Pick up Policy

I understand that if club staff are unable to contact a caregiver within 30 minutes of the end of Club programming, law enforcement and Child Protective Services may be notified.

Media/Photo Permission

I do give my permission to have my child appear in any media coverage for the Boys & Girls Club of Fond du Lac unless I have checked the box on the member information page stating that they may not appear in media coverage.

Travel Policy

I authorize BGCFDL to transport my child on field trips by bus or van within the local city during normal Club operating hours.

Program Participation

I understand that enrollment in the Boys & Girls Club School Year program requires participation in academic enrichment activities and academic support.

School District

I give permission to the BGCFDL and the Fond du Lac School District to exchange information regarding my child. The purpose of this exchange is to help both organizations do a better job of helping the student be successful in school, in the Club, and in life.

Teen Program Guide

I have read and understand the program guide(s) for the programs my children are in:
Click to read the Teen Program Guide here.
Signature*
Today's Date*
MM slash DD slash YYYY

Please Read Carefully

Boys & Girls Club of Fond du Lac is committed to providing safe use of technology and online safety for members. The acceptable use policy provides the framework for those safety practices and procedures.

Club Member Usage

Before a member will be allowed to use Club technology equipment or their personal device, both the member and his/her parent/guardian will need to read and sign the Technology Acceptable Use policy and return it to the Club.

Authorized Use

Club devices and personally owned devices are permitted for use during approved Club times for Club purposes and in approved locations only. The Club expressly prohibits the use of Club devices or personally owned devices in locker rooms, restrooms and other areas where there is an expectation of privacy.

Appropriate Use

Members may not use any technology to harass, threaten, demean, humiliate, intimidate, embarrass or annoy their peers or others in their community. Any inappropriate use of a Club or personally owned device, as determined by Club staff, can lead to disciplinary action including but not limited to confiscation of the device, immediate suspension from the Club, termination of membership or other disciplinary actions determined to be appropriate to the Club’s existing disciplinary policies including, if applicable, referral to local law enforcement.

Cyberbullying

Members may not utilize any technology to harass, threaten, demean, humiliate, intimidate, embarrass or annoy their peers or others in their community. This behavior is cyberbullying, which is defined as bullying that takes place using emerging technologies and devices. Any cyberbullying that is determined to disrupt the safety and/or well-being of the Club, Club members, Club staff or community is subject to disciplinary action.

Monitoring and inspection

Boys & Girls Clubs of Fond du Lac reserves the right to monitor, inspect, copy and review files stored on Club-owned devices or networks. In addition, BGCFDL reserves the right to inspect and/or review personally owned devices that are brought to the Club. Parents/guardians will be notified before such an inspection takes place and may be present, at their choice, during the inspection. Parents/guardians may refuse to allow such inspections but the member may be barred from bringing personally owned devices to the Club in the future.

Digital Citizenship

Club members shall conduct themselves online in a manner that is aligned with the BGCFDL Behavior Support Policy. The same rules and guidelines members are expected to follow offline (i.e., in the real world) shall also be followed when online. Should a member behave online in a manner that violates the BGCFDL Behavior Support Policy, that member shall face the same discipline policy and actions they would if their behavior had happened within the physical Club environment.

Technology Use Policy

I have read and understand the technology use policy for the programs my children are in:
Click to read the full 2024-2025 Technology Use Policy here.
Signature*
Today's Date*
MM slash DD slash YYYY

Payment & Completion
PLEASE NOTE:
School Year Program Fees are non-refundable. All registrations are subject to Boys & Girls Club of Fond du Lac Administration approval.
Total
$0.00
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Comments
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Teen Center School Year Program Registration

Teen Center School Year Program Registration 2024-25

Step 1 of 13

Parent/Guardian #1

Parent/Guardian #2

Child #1 Information

Child #2 Parent/Guardian Information

Parent/Guardian #1

Parent/Guardian #2

Child #2 Information

Child #3 Parent/Guardian Information

Parent/Guardian #1

Parent/Guardian #2

Child #3 Information

Emergency Contacts / Pick Up Information

Non Parent/Guardian #1 Emergency Contact

Non Parent/Guardian #2 Emergency Contact

Non Parent/Guardian #3 Emergency Contact

Signature and Agreement

Behavior Support & Expectations

Medical Emergency

Pick up Policy

Media/Photo Permission

Travel Policy

Program Participation

School District

Teen Program Guide

Club Member Usage

Authorized Use

Appropriate Use

Cyberbullying

Monitoring and inspection

Digital Citizenship

Technology Use Policy

Payment & Completion

First Name	Last Name

First Name	Last Name