Boys and Girls Club of Southern Maine

Child Name

Street Address

City

Child Birthday

Ethnicity/Race

American Indian or Alaska Native

Asian

Black or African-American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Some Other Race or Ethnicity

Two or More Races

Gender

Child lives primarily with: (check all that apply)

Primary Language at Home

Medical Info

MEDICAL INFORMATION

Other Medical Conditions:

Does the child have allergies or dietary restrictions?

Please check all the apply:

Please list any medications currently used by the child:

School Info

SCHOOL INFORMATION

Grade Starting Fall 2024:

SCHOOL COOPERATION RELEASE

SCHOOL COOPERATION RELEASE

As the child parent/guardian I give my permission to the Boys & Girls Clubs of Southern Maine to release the child's name listed on this application to their school in order to receive information regarding attendance, behavior in class and academic needs. The purpose of this is to help the organization do a better job of helping the child be successful in school, in the Boys & Girls Club and in life.

Yes

No

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:

Parent/Guardian Phone

Parent/Guardian Email

Relationship to child:

Preferred Method of Contact:

Phone Call

Text Message

Email

Emergency Contact Name (if parent/guardian cannot be reached):

Emergency Contact Phone number:

Emergency Contact's Relation to child

Optional Income Questions

The following questions will remain confidential.

How many members are in your household including yourself?

If you would like to be considered for a reduced fee, enter your monthly family income here:

PUBLIC RELATIONS RELEASE

PUBLIC RELATIONS RELEASE

PR TEXT

I give permission for the child listed on the application to have their name and/or pictures, portraits or such images, audio and/or video in advertising, news, social media, and/or any other promotional materials for Boys & Girls Clubs of Southern Maine (BGCSM), and for use or distribution in other non-BGCSM publications, electronic or otherwise, without notifying me. I waive any rights that I may have to inspect and/or approve the finished product that I or the child may have, including copyright. I agree to hold BGCSM harmless from any liability that may arise by virtue of any artistic or other distortion and/or alteration that may occur in the finished product.

PR Release

By checking this box I agree to the statement listed above,

PARENT/GUARDIAN AGREEMENT

PARENT/GUARDIAN AGREEMENT

Parent/Guardian Release

I hereby give my permission for my child to participate in this program. I understand that BGCSM and its personnel are not responsible for personal injury or loss of property. I hereby give permission to BGCSM to secure proper treatment for my child in case of emergency. I understand that there is a BGCSM Parent & Member Handbook that provides guidelines my child and I must adhere to. I may request a copy of the handbook at any time.

By initialing below, I agree to submit my form responses.

South Portland Middle School Program

2024/2025 Registration

South Portland Middle School Member Registration Form

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