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Registration

2023-2024 School Year

After School Enrollment

Step 1 of 9

11%

Before we can accept and begin our enrollment process, the Registration form must be filled out completely, the parent handbook must be signed and the $30.00 Registration fee must be paid.

CHILD INFORMATION

Name of Child(Required)

First Middle Last

Nickname(Required)

Home Phone(Required)

Child's Address(Required)

Street Address City State ZIP Code

Date of Birth(Required)

MM slash DD slash YYYY

Gender(Required)

Male

Female

Other

Other(Required)

Child's Race(Required)

African American

Asian

Caucasian

Multi-Racial

Hispanic

Native American

Other

Did your child attend BGCCC during the 2022-2023 school year?(Required)

Yes

No

Custody Dispute(Required)

Yes

No

Name of Parent/Spouse Who Cannot Pick up Child(Required)

Copy of Court Document Stating Conditions of Custody/Visitation Must Be Included with Member Application.

Is Your Child Enrolled In Any Special Education Program At School?

Yes

No

Check all that apply

ESE

ESOL

Other

List other special education programs

Select T-Shirt Size(Required)

YS

YM

YL

AS

AM

AL

AXL

SCHOOL INFORMATION

School Attending(Required)

Grade(Required)

Does your child receive free or reduced lunch at school?(Required)

Yes

No

Select Annual Household Income(Required)

$0 - $19,999

$20,000-$39,999

$40,000 - $59,999

$60,000 - $89,999

$90,000 and above

Please indicate Family Size(Required)

FAMILY INFORMATION

(please provide all requested information)

PARENT/GUARDIAN’S NAME(Required)

First Last

Pref. Phone #(Required)

EMAIL(Required)

Relation to Child(Required)

Address(Required)

Street Address City State ZIP Code

Place of Employment(Required)

Work Phone(Required)

Work Hours(Required)

Work Address(Required)

Street Address City ZIP Code

PARENT/GUARDIAN’S NAME

First Last

Pref. Phone #

EMAIL

Relation to Child

Address

Street Address City State ZIP Code

Place of Employment

Work Phone

Work Hours

Work Address

Street Address City ZIP Code

LATE PICK UP

The Boys & Girls Club of Westminster closes promptly each day at 6:00 pm. Pickup after 6:00 pm is considered to be late. Pickup after 6:00 pm [or 5:00 PM for camp/school breaks] is considered late. For any child remaining after the stated closing time, a late fee will be charged. Beginning at 1 minute passed the closing time a late fee of $1.00 per minute per family will be charged. The late fee must be paid in full before the child may return to the program. There will be no exception to this rule. We will notify the appropriate authorities for any child remaining 30 minutes after the close of business. I agree that I am responsible for picking up special notices and flyers each day which will alert me to any changes in scheduling. If someone else is picking up my family, I agree that they are responsible for picking up notices and flyers. I understand that if I am frequently late, my child’s membership may be revoked without refund.

Parent Signature(Required)

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date(Required)

MM slash DD slash YYYY

MEDICAL INFORMATION

Doctor Name(Required)

Doctor Phone(Required)

Permission to contact Doctor/Hospital in case of a medical emergency(Required)

Yes

No

Child’s Medical Insurance Provider(Required)

Policy Number(Required)

Group Number(Required)

MEDICAL LIMITATIONS

List any medical or physical limitations that would limit your child's participation in the program or that we should know about - (be specific)(Required)

BEHAVIOR

Does your child have any specific behavior conditions? (This does not restrict your child from enrolling)(Required)

Yes

No

Does your child have any specific behavior conditions? (This does not restrict your child from enrolling)(Required)

SLD

ADD

ADHD

Other

Please list behavior conditions(Required)

ALLERGIES

Does your child have any known allergies (such as dust, medicine, plants, animals, food, etc)(Required)

Yes

No

If yes, what are they allergic to?(Required)

MEDICATION

Is your child currently taking medication(s)?(Required)

Yes

No

List any medication(s) that your child is currently taking & the dosage. (If your child’s condition requires medication please note that we are unable to administer or hold as we do not have a nurse on site. Therefore, if medication (Epi-Pens, inhalers, etc) is needed member must keep them in their bag and be able to administer properly.) Please be specific(Required)

What is the specific medical condition that requires the above listed medication?(Required)

MEDICAL EMERGENCY

In case of accidental injury, the undersigned authorizes Boys & Girls Club of Westminster staff to see that the necessary medical treatment is obtained in the event the parent or legal guardian is unable to be reached or is otherwise inaccessible. In this event, the undersigned authorizes a Boys & Girls Club of Westminster Staff Member to sign for and authorize the physician (of his/her choice) to provide emergency care. In case of accidental injury, the undersigned agrees to assume financial responsibility for cost incurred.

I have read the above and agree to the stipulations.

Parent Signature(Required)

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date(Required)

MM slash DD slash YYYY

LEGAL AND/OR BEHAVIOR ISSUES

Please list any legal and/or behavior issues that your child is currently dealing with. This includes probation and the conditions of probation, behavior issues both in school or with law enforcement and any charges or allegations that they may be facing that are unresolved. (This does not restrict your child from enrolling.)(Required)

Does your child works with a Personnel Pupil Worker (PPW) or is assigned a counselor?

Yes

No

Name of Personnel Pupil Worker (PPW) or assigned a counselor

Phone

TRANSPORTATION/FIELD TRIP PERMISSION

I hereby give my permission for my child to participate in the activities and programs of the Boys & Girls Club of Westminster that necessitate transportation in vehicles. I understand that often local day trips will be unannounced. Out of town trips will be posted in advance. I understand that all trips will be under the supervision of the Boys & Girls Club of Westminster staff. I will not hold the Boys & Girls Club of Westminster responsible in case of an accident. Notice of all trips will always be available at the administrative office.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

SWIMMING PERMISSION

I hereby give my permission and full consent for my child to participate in swimming activities at local pools and facilities as conducted by the Boys & Girls Club. I hereby fully release the Boys & Girls Club of Westminster and its Directors, Instructors, Officers and Staff, from any cause of action, claim or liability for damages or expenses. These include, but not limited to any claims for personal injuries resulting or arising out of any swimming activity or related activities. I give permission to the Boys & Girls Club to administer sunscreen (as provided by parent) on my child as needed.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

BOYS & GIRLS CLUB RIGHT TO REFUSE PICK UP OF CHILD

I understand the Boys & Girls Clubs of Carroll County may refuse to allow my child to be transported home by anyone (including myself) that they feel may have their driving ability impaired due to drugs or alcohol or other circumstances. I understand that this is for safety reasons only and that the Boys & Girl Club of Westminster will contact another authorized individual included on this application to pick up my child. I further agree that any late fees incurred because of the situation will be my responsibility.

Parent Signature(Required)

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date(Required)

MM slash DD slash YYYY

COMPUTER USE PERMISSION

I hereby give my permission for my child to participate in the activities and programs of the Boys & Girls Clubs of Carroll County that use the internet. I understand that all computer use will be under the supervision of the Boys & Girls Club Staff. I understand my child may only go to internet sites that are pre-approved by the Boys & Girls Club Staff. I understand my child may only go to internet sites that are pre-approved by the Boys & Girls Club Staff. Any inappropriate use of the computer will result in suspension and may result in my child’s membership to be revoked.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

SCHOOL INFORMATION

I give permission to the Boys & Girls Clubs of Carroll County and Carroll County School Public Schools to exchange information including report cards, regarding the minor child listed on this application. The purpose of the exchange is to help both organizations to do a better job of helping the student be successful in school, in the Boys & Girls Club of Westminster and in life. This release is valid for one year and may be revoked at any time by contacting Carroll County School Public Schools or the Boys & Girls Club of Westminster in writing.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

SURVEYS & QUESTIONNAIRES

I, the parent/guardian of the minor child listed in this application, give permission for the Boys & Girls Clubs of Carroll County to Survey my child about his or her Club experience, behaviors, skills and attitudes using Boys & Girls Clubs of America’s National Outcomes Survey or other survey instruments.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

BOYS & GIRLS CLUBS OF AMERICA

I give permission to the Boys & Girls Clubs of Carroll County to share information about the minor child listed on this application with the Boys & Girls Club of America (BGCA) for research purposes and/or to evaluate the program’s effectiveness. Information that will be disclosed to BGCA may include the information provided on this membership application form, information provided by the minor child’s school or school data collected via surveys or questionnaires. All information provided to BGCA will be kept confidential.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

PHOTO/VIDEO RELEASE

I understand that from time to time, the Boys & Girls Clubs of Carroll County will have publicity photos and/or videos taken during programming for use in local media, brochures and on their website. I give permission for my child to be included in all photo opportunities with Boys & Girls Clubs of Carroll County and their partners.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

SIGNED AGREEMENT

These policies and procedures have been designed to ensure the safety of ALL Boys & Girls Clubs of Carroll County’s members.

*The Boys & Girls Club of Carroll County will follow all Carroll County Public School COVID-19 guidelines.

Please take the time to review them with your child. If you have any questions, please contact Raquel Warner, Program Director at 410-386-0135 ext 101 or rwarner@bgccarrollcounty.org

Agreements(Required)

I have read and agree to the Code of Conduct and Parent/Guardian Agreement as described in the School Year Agreements.

Parent Signature(Required)

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date(Required)

MM slash DD slash YYYY

PERSONS AUTHORIZED TO PICK UP CHILD INCLUDING YOURSELF

IF AUTHORIZED CONTACTS CHANGE PLEASE NOTIFY CLUB STAFF IMMEDIATELY

Name(Required)

First Last

Phone(Required)

Relationship(Required)

Emergency(Required)

Yes

No

Name

First Last

Phone

Relationship

Emergency

Yes

No

Name

First Last

Phone

Relationship

Emergency

Yes

No

Name

First Last

Phone

Relationship

Emergency

Yes

No

Do you have additional authorized persons?

Yes

No

Name

First Last

Phone

Relationship

Emergency

Yes

No

Name

First Last

Phone

Relationship

Emergency

Yes

No

PICK-UP POLICY

I understand that if myself or another pre-authorized individual is noticeably under the influence and/or otherwise unstable, BGC staff are legally obligated to withhold my member until alternative pick-up arrangements are made.

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

MEMBERS 13 & OLDER ONLY

PERMISSION TO WALK, DRIVE A CAR, OR RIDE A BIKE - HOME

I give permission for my child to check in/out each day. I understand that the Boys & Girls Club is not responsible for him/her before arrival to the Club or after they leave the program. I give permission for my child to:

Select One

Walk

Ride a Bike

Driving a Car

I give permission for my teen child to check in / out their younger siblings.

Yes

No

Parent Signature

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date

MM slash DD slash YYYY

HOUSEHOLD INFORMATION

This section Must Be Completed and is used for our information only. This information does not determine membership status and all information is kept confidential.

Reason for Joining Club (check all appropriate answers):(Required)

Fun

Academic Support

Sports

Friends are Members

School Referral

Enrichment Programs

Other

Other(Required)

The Club Member lives with (check all that apply):(Required)

Mom

Dad

Step Mom

Step Dad

Grandparent

Guardian

Other

Other(Required)

Single Parent(Required)

Yes

No

Current head of household (check one):(Required)

Male

Female

Both

Number of people living in household(Required)

Number of household members 65+(Required)

Parent in the Military?(Required)

Yes

No

Branch(Required)

Parent Incarcerated?(Required)

Yes

No

Previously

When/How Long:(Required)

Are there other children in the household who will be attending the Boys & Girls Club After School/Summer Camp Program?

Yes

No

Name

First Last

Grade

Age

Name

First Last

Grade

Age

CARROLL COUNTY PUBLIC SCHOOLS TRANSPORTATION PERMISSION LETTER

Carroll County Public Schools, East Middle School, West Middle School, William Winchester Elementary School, Friendship Valley Elementary School, Westminster Elementary School, Cranberry Station Elementary School, Robert Moton Elementary School, Winters Mill High School, and Westminster High School have partnered with the Boys and Girls Club of Westminster located at 71 E Main Street, Westminster, MD., to provide a quality after-school program for students. Subject to available space, Carroll County Public Schools will provide school bus transportation at no cost to participating families. Students will be transported on an approved school bus using existing school bus routes.

The bus will drop club members off at the closest bus stop to the Boys & Girls Club of Westminster. The Boys and Girls Club of Westminster, MD, will be responsible for students once they disembark the bus at the bus stop. Parents need to make it clear to their children that they are to disembark the bus at their appropriate bus stop and go directly to the present Boys and Girls Club staff member.

Only students at East MS, West MS, William Winchester ES, Friendship Valley ES, Westminster ES, Cranberry Station ES, Robert Moton ES, Winters Mill HS, and Westminster HS who have enrolled in the Boys and Girls Club of Westminster after-school program are eligible to ride the school bus. Families are responsible f or picking up students at the conclusion of the program.

Thank you, Boys and Girls Club of Westminster

Transportation Permission Form

What school will your child ride the bus from at the conclusion of the school day?(Required)

Select the days you expect your child to ride the bus to the Boys and Girls Club(Required)

Monday

Tuesday

Wednesday

Thursday

Friday

I give my permission for my child to ride the approved school bus on the days listed above, unless there is a special exception. I will notify both the school and the Boys and Girls Club if my child will not be attending on a day they are scheduled to attend. I will also notify both the school and the Boys and Girls club of any permanent changes. I understand that I am responsible for picking up my student at the conclusion of the after-school program.

Parent Signature(Required)

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Phone(Required)

Will you attend the Westminster Club House?(Required)

Yes

No

ALTERNATE EMERGENCY CONTACT AND CLOSURE PLAN FOR YOUR CHILD

Please indicate below what you have instructed your child and school to do in case of inclement weather

EMERGENCY CONTACT INFORMATION

Emergency Contact (Parent or Legal Guardian)(Required)

First Last

Phone(Required)

Relation to Child(Required)

2nd Emergency Contact (Other than Parent Above)

First Last

Phone

Relation to Child

ALTERNATIVE EMERGENCY CONTACTS

Primary Emergency Contact(Required)

First Last

Home Phone(Required)

Work Phone

Secondary Emergency Contact

First Last

Home Phone

Work Phone

Emergency Dismissal Plan(Required)

Parent Signature(Required)

By entering your name below and submitting this electronic application, you are consenting to the use of your electronic signature in lieu of an original signature on paper.

First Last

Date(Required)

MM slash DD slash YYYY

How will you be paying your registration fee?(Required)

Pay Online

Pay Cash or Check

Membership fees are non-refundable. Payment guarantees membership but does NOT guarantee transportation. Please call 410.386.0135 to check ridership for your school(s).

Registration Fee

Price:

Credit Card Fee

Price: $0.00

Total

Billing Address(Required)

Use address from Parent/Guardian 1

Street Address Address Line 2 City State ZIP Code

Credit Card(Required)

Card Details

Cardholder Name

CAPTCHA

The 2024 - 2025 After School Program Registrations will begin in August 2024. Please check back for more information

Boys & Girls Clubs of Carroll County | 410-386-0135 | info@bgccarrollcounty.org | 71 E. Main Street, Westminster, MD 21157 | Member of the Boys & Girls Clubs of America

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