Summer 2024 Registration - NEW Member

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NEW MEMBERSHIP & SUMMER REGISTRATION

Please fill in all of the below information to complete registration for our Summer Program.

Our staff will inform you via email or phone call if further forms or information is necessary.

Once you fill out the form, you will be redirected to another page with further details about fee payment and other details to know.

Membership Application

Which Club Will Member Attend?

Kewaskum Members - Please select the program options your child will attend

After Summer School Program

Will be transferring to another Club at the conclusion of the summer program

NOT A KEWASKUM MEMBER

Kewaskum Members - If your child will be transferring to another Club at the conclusion of the summer school program in June, which Club will they transfer to?

Hartford, Jackson, & West Bend Members - Please select the MORNING program option your child will attend

Hartford, Jackson, West Bend Members - Extended Summer Program: Will your child need to attend the Extended Summer Program Aug. 19-23 (Additional $50 charge per child)

Yes

No

Uncertain at this point

Hartford Members - Summer School Transportation: Select which option your child will need (if more than 36 kids, a transportation charge of $20 will be charged to cover RiteWay Bus Fee)

Member First Name

Member Middle Name

Member Last Name

Member Home Address (Street, City, State, Zip)

Date of Birth

Current Age

Grade

What School Does Your Child Attend?

Who does the Member live with?

Gender

Nationality

Number of Children in Household Under 18

Medical Condition(s) / Allergies - If none put NA

Medication(s) - If none put NA

PRIMARY Parent/Guardian Name (First & Last)

PRIMARY Parent/Guardian Relation to Child

PRIMARY Parent/Guardian Employer

PRIMARY Parent/Guardian Cell Phone

PRIMARY Parent/Guardian Work Phone

PRIMARY Parent/Guardian Email Address

Secondary Parent/Guardian Name (First & Last)

Secondary Parent/Guardian Relation to Member

Secondary Parent/Guardian Employer

Secondary Parent/Guardian Cell Phone

Secondary Parent/Guardian Work Phone

Secondary Parent/Guardian Email Address

Emergency Contact 1 (First & Last) - Cannot be a name used above

Emergency Contact 1 Phone Number

Emergency Contact 1 Relation to Member

Emergency Contact 2 Name (First & Last) - Cannot be a name used above

Emergency Contact 2 Phone Number

Emergency Contact 2 Relation to Member

Emergency Contact 3 Name (First & Last) - Cannot be a name used above

Emergency Contact 3 Phone Number

Emergency Contact 3 Relation to Member

Check all that apply - Required for funding purposes

SSDI

SSI

TANF

SNAP / FoodShare

Free / Reduced Lunch

None of the Above

Estimated Annual Household Income - Required for funding purposes

Military Affiliation of Parent/Guardian?

How did you hear about us?

Shirt Size (members will receive a free shirt in the 2023/2024 membership year)

Leaders of Tomorrow Permission - I, the Parent/Guardian of the child listed on this application hereby give my permission for my child to participate in the Leaders of Tomorrow mentoring program at the Boys & Girls Club. Please type your name in the box below to submit as an electronic signature. If you do not wish for your child to participate, please put NA.

Parent/Guardian Signature - Writing your name in the line below signifies that you have read and completed the membership application, have read and agree to all policies and conditions stated in the Parent/Guardian & New Member Handbook as well as the Parent/Guardian Operations Manual, understand the expectations set forth by the Boys & Girls Clubs of Washington County for members and families, and request that your child be admitted into membership.

Click the box below if you have a promotional membership document. If you do, you will be required to turn into your Unit Director to complete membership.

I have a promotional form for my child(ren)'s mem

Thank you for submitting your child's application. A staff from the Club will be reaching out in the next 48 hours to confirm receipt of this application. If you have not heard back, please call us in the event of any technical issues. Thanks!

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Boys & Girls Clubs of Washington County

925 N. Silverbrook Drive

West Bend, WI

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