BGC Middle School 2023-24 Enrollment Form
Form must be fully completed and submitted prior to attendance. 
One form must be submitted for each child attending.  
The cost for ANNUAL membership is $20 for each child not to exceed $50 per family.  You may join at any time, however, ALL memberships will expire on August 31, 2024.  Please see our Membership Coordinator for payment.

For Questions and status of application please contact the Membership Coordinator at (715) 736-7445
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Email *
Location for enrollment *
Child's full name (First, Last name) *
Child's Nickname 
Address, City, Zip Code, State *
Gender *
Date of Birth *
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School: *
Grade as of September 2023 *
Teacher *
Teacher Email (if known)
Is there anything you feel would be helpful for our staff to be aware of with regard to your child's academic abilities? (This will give us the background to provide your child with extra homework assistance if needed). *
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? *
Please list your child's interests and hobbies. *
Please list information on your family dynamic that would be helpful for our staff to know (foster parents, split household, recent divorce, etc.) 
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Please list any behavioral concerns with your child and possible triggers.  Include anything that would be helpful for us to know.
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(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
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Relationship to Child
 *
Emergency Contact #2 Phone Number
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Emergency Contact #2 Address (Street, City, State, Zip Code)
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Is this individual allowed to pick up your child from the Club in your absence  
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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)  
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 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   
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We are required to report the following information below to assist us in our search for outside funding to better serve our membership.  Information may be collected for statistical purposes.  All information will be kept confidential.  Your assistance is very much appreciated.
Number of people in household *
Annual Income: *
  Is this child eligible for free or reduced lunch?  
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Does your child qualify for any of the following programs (check all that apply)
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Required
  Child lives with (check all that apply)  
 *
Required
  Child’s ethnicity  
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  Is your child part of a military family?   
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  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.  
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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.  
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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.  
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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.  
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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.   
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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.  
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Electronic Signature *
By selecting the "I Accept" button, you are signing this Agreement electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature on this Agreement. *
This form must be fully completed along with payment submitted prior to attendance. For Questions and status of application please contact the your designated site:

Rice Lake Middle School 
Cumberland Middle School 715-822-5124 ext.240
Barron Riverview Middle School  

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.
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