Member 1 Name*
First
Last
Living with* Select One Mother Father Both Joint Custody Foster Family Grandparent Other (please specify)
Date of Birth* Grade* Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Gender* Male Female Transgender Non-binary
Ethnicity* Hispanic or Latino Not Hispanic or Latino
Race* Select One White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Biracial or Multiracial Other (please specify)
List anyone not allowed to pick up child by court order A document is needed if there are any custody orders involving restrictions or limitations of when any parent or guardian is allowed to drop off or pick up.
Site Information Select at least one option from the list below.
School Year 2022-2023 Morning snack will be served.
KIDSTOP Site* Select One Mississippi Heights Oak Ridge Pine Meadow Pleasantview Riverview
Day(s) Attending School Year 2022-2023 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Lincoln Madison Oak Hill Oak Ridge Talahi Westwood
Day(s) Attending Summer 2023 Morning and afternoon snack will be served.
KIDSTOP Site* Select One Clearview Kennedy Madison Mississippi Heights Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending School Year 2023-2024 Morning snack will be served.
KIDSTOP Site* Select One Mississippi Heights Pleasantview Pine Meadow Oak Ridge Riverview
Day(s) Attending School Year 2023-2024 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Madison Mississippi Heights Oak Hill Oak Ridge Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending
Medical Information The questions below are designed to help us understand and work effectively with your child. You are not required to answer these questions; however, the lack of this information may affect our ability to work with your child.
Describe any unusual health conditions of the child:
This question is designed to help us understand and work effectively with your child. You are not required to answer these questions: however, the lack of this information may affect our ability to work with your child.
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?* No Yes
Has your child experienced any emotional trauma?* No Yes
Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?* No Yes
I give permission to the staff at BGC/KIDSTOP to apply suncreen during programming.*
Member 2 Name*
First
Last
Living with* Select One Mother Father Both Joint Custody Foster Family Grandparent Other (please specify)
Date of Birth* Grade* Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Gender* Male Female Transgender Non-binary
Ethnicity* Hispanic or Latino Not Hispanic or Latino
Race* Select One White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Biracial or Multiracial Other (please specify)
List anyone not allowed to pick up child by court order A document is needed if there are any custody orders involving restrictions or limitations of when any parent or guardian is allowed to drop off or pick up.
Site Information Select at least one option from the list below.
School Year 2022-2023 Morning snack will be served.
KIDSTOP Site* Select One Mississippi Heights Oak Ridge Pine Meadow Pleasantview Riverview
Day(s) Attending School Year 2022-2023 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Lincoln Madison Oak Hill Oak Ridge Talahi Westwood
Day(s) Attending Summer 2023 Morning and afternoon snack will be served.
KIDSTOP Site* Select One Clearview Kennedy Madison Mississippi Heights Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending School Year 2023-2024 Morning snack will be served.
KIDSTOP Site* Select One Mississippi Heights Pleasantview Pine Meadow Oak Ridge Riverview
Day(s) Attending School Year 2023-2024 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Madison Mississippi Heights Oak Hill Oak Ridge Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending
Medical Information The questions below are designed to help us understand and work effectively with your child. You are not required to answer these questions; however, the lack of this information may affect our ability to work with your child.
Describe any unusual health related conditions of the child
This question is designed to help us understand and work effectively with your child. You are not required to answer these questions: however, the lack of this information may affect our ability to work with your child.
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?* No Yes
Has your child experienced any emotional trauma?* No Yes
Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?* No Yes
I give permission to the staff at BGC/KIDSTOP to apply suncreen during programming.*
Member 3 Name*
First
Last
Living with* Select One Mother Father Both Joint Custody Foster Family Grandparent Other (please specify)
Date of Birth* Grade* Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Gender* Male Female Transgender Non-binary
Ethnicity* Hispanic or Latino Not Hispanic or Latino
Race* Select One White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Biracial or Multiracial Other (please specify)
List anyone not allowed to pick up child by court order A document is needed if there are any custody orders involving restrictions or limitations of when any parent or guardian is allowed to drop off or pick up.
Site Information Select at least one option from the list below.
School Year 2022-2023 Morning snack will be served.
KIDSTOP Site* Select One Mississippi Heights Oak Ridge Pine Meadow Pleasantview Riverview
Day(s) Attending School Year 2022-2023 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Lincoln Madison Oak Hill Oak Ridge Talahi Westwood
Day(s) Attending Summer 2023 Morning and afternoon snack will be served.
KIDSTOP Site* Select One Clearview Kennedy Madison Mississippi Heights Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending School Year 2023-2024 Morning snack will be served.
KIDSTOP Site* Select One Mississippi Heights Pleasantview Pine Meadow Oak Ridge Riverview
Day(s) Attending School Year 2023-2024 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Madison Mississippi Heights Oak Hill Oak Ridge Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending
Medical Information The questions below are designed to help us understand and work effectively with your child. You are not required to answer these questions; however, the lack of this information may affect our ability to work with your child.
Describe any unusual health related conditions of the child
This question is designed to help us understand and work effectively with your child. You are not required to answer these questions: however, the lack of this information may affect our ability to work with your child.
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?* No Yes
Has your child experienced any emotional trauma?* No Yes
I give permission to the staff at BGC/KIDSTOP to apply suncreen during programming.* Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?* No Yes
Member 4 Name*
First
Last
Living with* Select One Mother Father Both Joint Custody Foster Family Grandparent Other (please specify)
Date of Birth* Grade* Kindergarten 1st Grade 2nd Grade 3rd Grade 4th Grade 5th Grade 6th Grade
Gender* Male Female Transgender Non-binary
Ethnicity* Hispanic or Latino Not Hispanic or Latino
Race* Select One White Black or African American Asian American Indian or Alaskan Native Native Hawaiian or Other Pacific Islander Biracial or Multiracial Other (please specify)
List anyone not allowed to pick up child by court order A document is needed if there are any custody orders involving restrictions or limitations of when any parent or guardian is allowed to drop off or pick up.
Site Information Select at least one option from the list below.
School Year 2022-2023 Morning snack will be served.
KIDSTOP Site* Select One Mississippi Heights Oak Ridge Pine Meadow Pleasantview Riverview
Day(s) Attending School Year 2022-2023 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Lincoln Madison Oak Hill Oak Ridge Talahi Westwood
Day(s) Attending Summer 2023 Morning and afternoon snack will be served.
KIDSTOP Site* Select One Clearview Kennedy Madison Mississippi Heights Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending School Year 2023-2024 Morning snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Madison Mississippi Heights Oak Hill Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending School Year 2023-2024 Afternoon snack will be served.
KIDSTOP Site* Select One Clearview Discovery Kennedy Madison Mississippi Heights Oak Hill Pine Meadow Pleasantview Riverview Talahi Westwood
Day(s) Attending
Medical Information The questions below are designed to help us understand and work effectively with your child. You are not required to answer these questions; however, the lack of this information may affect our ability to work with your child.
Describe any unusual health related conditions of the child
This question is designed to help us understand and work effectively with your child. You are not required to answer these questions: however, the lack of this information may affect our ability to work with your child.
Does your child have any physical or mental disabilities, developmental delays or emotional/behavioral disorders that we should be aware of the help your child be successful in Club?* No Yes
Has your child experienced any emotional trauma?* No Yes
I give permission to the staff at BGC/KIDSTOP to apply suncreen during programming.* Note: If you answered yes to either of the above two questions, an intake questionnaire will be provided for you, to detail your child's specific needs to insure success for your child.
Is your child receiving any services through Special Education?* No Yes
Where did you learn about us? If other, please describe