Boys & Girls Clubs of North Central NC | Empowering Youth Potential

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Teen Court

Contact

About Us
- Child Safety
- Community/Program Partners
Our Clubs
Events
Our Blog
Contact
Ways to Support
- Donate Now
Summer Camp
Teen Court

PARENT PORTAL

DONATE

Warren Summer Camp Application Registration

First:

MI:

Last:

Nickname:

Gender:

Male

Female

Date of Birth:

Age:

Race/Ethnicity:

T-Shirt Size:

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School Information for FALL 2025

School (Fall 2025):

Rising Grade Level (Fall 2025):

Special Education, IEP, Curriculum Assistance:

Yes

Child’s strongest subjects in school?

Child’s weakest subjects in schools?

Has your child ever repeated a grade?

Yes

If yes, which grade?

Does your child receive free or reduced lunch?

Yes

Did your child attend our clubs during the school year?

YES

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If no, please complete a membership application online at www.bgcncnc.com.

New memberships require a $12 membership fee.

Primary Contact Information

First Name:

Last Name:

Relation:

Cell Phone:

Email:

2nd Primary Contact Information (if applicable)

First Name:

Last Name:

Relation:

Cell Phone:

FOR OFFICE USE ONLY: Member #:

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Enter your free text here

List any medical or physical limitations that would limit your child’s participation in the summer program or that we should know about (please be specific):

Health/Behavioral Concerns: Please be honest and share any diagnosis, struggles, triggers, challenges or helpful information so that staff can best assist your child. If BGCNCNC makes a behavior/health discovery that we are not qualified or equipped to handle, your child’s membership/attendance may be revoked. es No If yes, explain

Medications: Yes, No

Allergies

Permission to Administer Medication (if needed)

I give permission for my child to be given the following medication:

Name of Medication:

Expiration Date:

Dosage:

Refrigerate

Dates to be Given:

Times to be Given:

Special Instructions:

*Medicine must be provided in an original bottle prescribed by physician. Medicine must be checked in with a staff member* An additional medication form will be required.

Parent’s Signature:

Date:

Emergency Contact Information (Person(s) Authorized to Pickup Member)

Name:

Ph.#:

Relationship:

Name:

Ph.#:

Relationship:

FOR OFFICE USE ONLY: Member #:

Transportation Permission (please initial)

I hereby give my permission for my child to participate in activities and programs with the Boys & Girls Club that necessitate transportation in vehicles. I understand that often local day trips may be unannounced; while out of town trips will be posted in advance. I understand that all trips will be under the supervision of the Boys & Girls Club staff. I will not hold the Boys & Girls Clubs of North Central North Carolina responsible in case of an accident. Notice of all trips all always be available at the administrative office.

YES

Swimming Permission (please initial)

I hereby give my permission and full consent for my child to participate in swimming activities at local pools as conducted by the Boys & Girls Club. I hereby fully release, and shall in the future release, the Boys & Girls Clubs of North Central North Carolina and its directors, instructors, officers and staff, from any cause of action claim or liability for damages or expenses, including but not limited to any claims for personal injuries resulting or arising from any swimming activity or related activities

YES

I do hereby give my child permission to attend and participate in the activities sponsored by BGCNCNC. Further, I will be responsible for any damage that his/her actions may cause. I hereby release the BGCNCNC, its employees, associates, and contributors from personal liability from any injury, loss of theft incurred by my child while participating. I hereby authorize medical examination and emergency treatment for my child by a qualified licensed physician in the event of an accident. I authorize the Club to administer first aid, in case of injury. (Every attempt will be made to contact parents/guardians on file). If any injury appears serious enough for hospitalization or medical care, such expense will be borne by parents or guardians. I give my consent to the Boys & Girls Clubs of North Central North Carolina, Inc. Further, I give permission for my child’s photograph or likeness to be used in BGCNCNC brochures, flyers, social media, newspaper articles, displays, etc. Parent/Guardian’s Initials

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My signature indicates that I completely understand the above statements.

Print Parent/Guardian Name:

Parent/Guardian Signature:

Date:

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**ALL MEMBERS MUST HAVE A CURRENT & UPDATED MEMBERSHIP

(INCLUDING APPLICATION), TO ATTEND THE SUMMER DAY CAMPS**

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