Kahlert Leadership Academy Registration - Boys & Girls Clubs of Carroll County

Select Registration For:(Required)

High School

Middle School

High School Registration For Session:

Please select one session.

June 24th-June 28th

August 5th-August 9th

Middle School Registration For Session:

Please select one session.

July 8th-July 12th

August 12th-August 16th

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)

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 2023-2024 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)

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

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

TRANSPORTATION/FIELD TRIP 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 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 Clubs of Carroll County staff. I will not hold the Boys & Girls Clubs of Carroll County 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

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 Clubs of Carroll County 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.

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

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 & Girls Clubs of Carroll County 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)

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. 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

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 Clubs of Carroll County 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 Clubs of Carroll County 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

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

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

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

SIGNED AGREEMENT

These policies and procedures have been designed to ensure the safety of ALL Boys & Girls Clubs of Carroll County’s members. Please take the time to review them with your child. If you have any questions, please contact us at 410-386-0135 or tschoolman@bgccarrollcounty.org

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)

CARROLL HOSPITAL CENTER: CONSENT FOR THE TREATMENT OF MINORS IN PARENTS ABSENCE

Parents Doctor(Required)

Choice of Specialist(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)

PAYMENT OPTIONS

Each session of the Kahlert Leadership Academy is $150. The $150 fee will cover the yearly BGC membership fee of $30. Enrollment in the Leadership Academy will cover the cost of After School Program enrollment for the 24-25 school year.

How would you like to pay for the session?(Required)

Pay Now by Credit Card

Pay Later by Check or Phone

Subtotal

$0.00

Credit Card Fee

Price: $0.00

Total

Billing Name

First Last

Billing Address

Same as Parent/Guardian One

Street Address Address Line 2 City State ZIP Code

Credit Card

CAPTCHA

Registration

2024 KLA Registration

CHILD INFORMATION

SCHOOL INFORMATION

FAMILY INFORMATION

LATE PICK UP

PERSONS AUTHORIZED TO PICK UP CHILD INCLUDING YOURSELF

MEMBERS 13 & OLDER ONLY

HOUSEHOLD INFORMATION

MEDICAL INFORMATION

MEDICAL LIMITATIONS

BEHAVIOR

ALLERGIES

MEDICATION

MEDICAL EMERGENCY

LEGAL AND/OR BEHAVIOR ISSUES

TRANSPORTATION/FIELD TRIP PERMISSION

SWIMMING PERMISSION

BOYS & GIRLS CLUB RIGHT TO REFUSE PICK UP OF CHILD

COMPUTER USE PERMISSION

SCHOOL INFORMATION

SURVEYS & QUESTIONNAIRES

BOYS & GIRLS CLUBS OF AMERICA

PHOTO/VIDEO RELEASE

SIGNED AGREEMENT

CARROLL HOSPITAL CENTER: CONSENT FOR THE TREATMENT OF MINORS IN PARENTS ABSENCE

PAYMENT OPTIONS

Kahlert Leadership Academy Fees

Sibling Discount

Costs

Hours of Operations

Who can attend?

Medications

Pickup

Sessions