Summer Program Registration

How many children will you be registering?*
- 1
- 2
- 3
- 4
- 5
Please list the names of all children you are registering*
First Name Last Name

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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

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Are you in need of financial assistance?*
Summer Program Fees (annually): $230/child for youth going into 2nd-5th grade $175/child for youth going into 6th-12th grade
- Yes
- No
Yearly Household Income*
Please share your exact yearly household income:*
Please list your family’s exact yearly household income. If you filed your 2021 Tax Return, this amount is your Total Income amount.
Please list any factors that may affect your ability to pay summer program fees:

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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
Pick Up Password*
This password must be given when picking up your child.
Late pickup agreement*
By checking the box, I understand that if my child is not picked up by 5:00pm, I will be charged a $5.00 fee. I also understand that if my child is not picked up within 15 minutes of closing time, the Club will contact the police to ensure my child’s safe return to home.
Agree*

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Signature and Agreement
Please Read Carefully

Behavior Policy & Expectations

I have read and understand the Boys & Girls Club of Fond du Lac’s PBIS Expectations and Behavior Policy. 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, and that failure to follow these policies will result in specific consequences for members that could result in temporary or permanent suspension from the program without a refund of membership fees. Read the PBIS Expectations and Behavior Policy 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.

Open Door Policy

I understand that the BGCFDL has an open door policy. This policy means that my child is welcome at any time. It is my responsibility to be sure that my child understands their departure procedure from the Club. I understand that teen center members are able to leave once and return once with my permission. I understand that the Club is not responsible for my child once they have left the building.

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 foot, bus or van within the local city during normal Club operating hours.

Program Participation

I understand that my children in the elementary program will be participating in summer school programming in the morning and Boys & Girls Club programming in the afternoon. Participation in these programs is required.

YMCA Policy

I understand that all usage of The Y facilities during program hours will be scheduled Boys & Girls Club program time and all members will be supervised as part of a Boys & Girls Club group. I also understand that if my child is suspended from either organization they are not allowed to enter the other organization during their suspension.

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.

Parent Guide

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

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Payment & Completion
PLEASE NOTE:
Summer 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
This field is for validation purposes and should be left unchanged.

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Summer Program Registration

2022 Summer Registration

Step 1 of 15

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

Child #4 Parent/Guardian Information

Parent/Guardian #1

Parent/Guardian #2

Child #4 Information

Child #5 Parent/Guardian Information

Parent/Guardian #1

Parent/Guardian #2

Child #5 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 Policy & Expectations

Medical Emergency

Open Door Policy

Media/Photo Permission

Travel Policy

Program Participation

YMCA Policy

School District

Parent Guide

Payment & Completion

First Name	Last Name

First Name	Last Name