Cumberland Middle School Enrollment Form
Form must be fully completed and submitted prior to attendance. One form must be submitted for each child attending. For Questions and status of application please contact the CMS Site at 715-822-5124 ext 240

Cumberland Middle School charges a fee of $20 per child.
Sign in to Google to save your progress. Learn more
Email *
Child's full name (First, Last name) *
Child's Nickname 
Address, City, Zip Code, State *
Gender *
Date of Birth *
MM
/
DD
/
YYYY
Grade as of September 2022 *
School *
Transportation Home *
Does your child have permission to walk home from Boys and Girls Club? *
Is there anything that you feel would be helpful for our staff to be aware of with regards to your child (disabilities, fears, etc.)?    *
Child's Medical Insurance Company *
Insurance Policy Number
Child's Physician *
Physician Phone Number *
Any Known Allergies  *
Any Medical Conditions we should be aware of? *
Child's interests or hobbies?  *
Please list your child’s favorite school subjects & any subjects they may struggle in.  
 *
Please list triggers or anything that would be helpful for our staff to be aware of with your child. It would be helpful to include family dynamic information as well (living with single parent, foster information, etc).   
 *
(1) Primary Parent/ Guardian Name (first and Last) *
Relationship to Child *
(1) Parent/ Guardian Address (Street, City, State, Zip code) *
Email Address *
Parent Primary Phone number *
Secondary Phone Number *
Employer  *
Job Title *
(2) Parent/ Guardian Name (First, Last) *
Relationship to Child *
(2) Parent/Guardian Address (Street, City, State, Zip Code)  *
Email Address *
Primary Phone number *
Secondary Phone Number *
Employer  *
Job Title *
Emergency Contact #1 Name *
Relationship to Child *
Emergency Contact #1 Phone Number *
Emergency Contact #1 Address(Street, City, State, Zip Code) *
Is this individual allowed to pick up your child from the Club in your absence  
 *
Emergency Contact #2 Name
 *
Relationship to Child
 *
Emergency Contact #2 Phone Number
 *
Emergency Contact #2 Address(Street, City, State, Zip Code)
 *
Is this individual allowed to pick up your child from the Club in your absence  
 *
Please list 2 additional individuals who are allowed to pick up your child from the Club (Please include name, phone number, and relation to yourself and your child)  
 *
 Are there any individuals that should NOT be allowed to pick up your child?, If “Yes” please list the following information: Name, Reason, Relationship to Child   
 *
The following information is for grant funding purposes only and is required by all members.  Information is kept private nor will it affect your child's ability to attend.
Number of people in household *
Annual Income: *
  Is this child eligible for free or reduced lunch?  
 *
Does your child qualify for any of the following programs: (check all that apply)
 *
Required
  Child lives with (check all that apply)  
 *
Required
  Child’s ethnicity  
 *
  Is your child part of a military family?   
 *
  If YES,
Clear selection
Who is the member of the family in the military and which Branch of Service?
Is the member currently deployed ? 
Clear selection
MEMBER MEDIA/PHOTO RELEASE: I give consent for photographs to be taken of my child to be used in displays, brochures, newsletters etc., exclusively for the Boys & Girls Clubs of Barron County. I give permission to use pictures, audio, videos, electronic images, and/or other works of my child in club-related publications, advertisements, media files, internet website, or any other photo or media outlet.   
 *
TECHNOLOGY: I give permission for my child to use the computers with internet access. All members will complete the NetSMARTZ program (a national Boys & Girls Club Internet safety course) prior to any activities on the computer. Boys & Girls Club members may access sites approved by Club Staff members, such as math games, etc. Members are not allowed to access email accounts or live chat room sites at the Club unless it is part of a structured program activity. Parents/guardians should notify Club staff if they wish to prohibit access to certain websites.  
 *
MEMBER ITEMS: I understand the Boys & Girls Clubs of Barron County is not responsible for lost or stolen items. Members are responsible for the care and storage of any items, such as electronics or clothing, which are brought into the club.  
 *
SURVEY & QUESTIONNAIRES: I give permission for Boys & Girls Clubs of Barron County to survey my child about his or her Club experience, behaviors, skills, and attitudes using Boys & Girls Clubs of America’s National Youth Outcomes Survey or other survey instruments. Participation of youth in surveys will follow Title 34 guidelines by the U.S. Department of Education. Any and all information received will be kept strictly confidential. Data gathered through these means will exclude all references to any individual responses. The aggregated results of these analyses may be shared with Club staff, Boys & Girls Clubs of America, funders, and other community stakeholders to evidence program effectiveness and/or Club impact on our members.  
 *
MEDICAL TREATMENT: I will not hold the Boys & Girls Clubs of Barron County responsible in case of injury from my child’s activities in the Club program and I give consent to seek emergency medical treatment by a physician or hospital in case of an accident. I will be responsible for any/all costs of medical attention and treatment. Note: The Boys & Girls Clubs of Barron County does not have access to the medications that your children have access to during the school day. If this is a concern, please let us know right away. Our policy states that we do not administer medication unless a Medication Administration Form is filled out. If you need this form, please contact the Site Director. It is the parent's responsibility to supply medication as needed, please read the Parent Handbook for more information.  
 *
PERMISSION TO USE FACILITIES: I have received the Parent/Member Handbook and understand that an orientation will be done with my child before their first day at the Boys & Girls Club. My child understands that membership constitutes the use of the facilities in a respectful manner and agrees to comply to the best of their ability with all rules and regulations as dictated by the Boys & Girls Clubs of Barron County. I waive all rights for claims against the Boys & Girls Clubs of Barron County, its Board of Directors, Officers, Staff or Volunteers for any damages or injuries which may occur during my child’s participation in Club-sponsored activities.   
 *
Required
I grant, the Boys & Girls Clubs of Barron County my permission to obtain school records, transcripts, grade reports (report cards and progress reports) and standardized test results through partnering school districts and their online grading systems including Skyward, PowerSchool, etc. I give the Boys & Girls Clubs of Barron County permission to seek educational information about my child from their school and communicate with their school guidance counselor about my child’s performance at school. I have read the completed application and waiver, understand the rules of the Boys & Girls Clubs of Barron County, and request that my child be admitted into membership. I will notify the Club of any changes in any information listed on the membership application. I hereby give my permission for my child to join the Boys & Girls Clubs of Barron County and to participate in all Club Activities and acknowledge that my child is fit and capable of participating in these activities.  
 *
This form must be fully completed along with payment submitted prior to attendance. For Questions and status of application please contact the Lincoln Clubhouse at 715-736-7445. 

Upon submission a staff member will review your form and be in contact within 48 hours.  No child is allowed to attend the Club without confirmation from the Site Director and without completing an orientation session.
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of Boys and Girls Clubs of Barron County. Report Abuse
Google Forms