1 Start 2 Contacts 3 Demographics 4 Transportation 5 Releases 6 Complete Application Location * Harrington Clubhouse Program * After School 2023-24 Member * Are you a previous member already registered at any of our Boys & Girls Clubs? No I am a Brand New Member Starting in September 2023 and Need a New Member Orientation Yes at Harrington Clubhouse Prior to September 2021 and Need a New Member Orientation Yes at Harrington Clubhouse Since September 2021 Yes at Great Brook Valley Yes at Plumley Village Applicant Information (Child's Information) Name * First Name First Name Middle Name(s) Middle Name(s) Last Name Last Name Generational -- Jr.Sr.IIIIIIIVVVIVIIVIIIIXX Generational Member Nickname Date of Birth * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year2001200220032004200520062007200820092010201120122013201420152016 Age Gender * Female Male Current Address * Address 1 * Address 2 City * State * - Select -AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming--Armed Forces (Americas)Armed Forces (Europe, Canada, Middle East, Africa)Armed Forces (Pacific)American SamoaFederated States of MicronesiaGuamMarshall IslandsNorthern Mariana IslandsPalauPuerto RicoVirgin Islands ZIP code * Home Phone * Cell Phone Work Phone School Name * - Select -1st. LT. Charles W. Whitcomb Middle School (Malboro)Abby Kelley Foster CharterACT Program at Chandler MagnetAlgonquin Regional High SchoolAlhuda AcademyAlternative School at St Casmir'sAuburn High SchoolAuburn Middle SchoolBancroft SchoolBelmont StreetBlackstone Valley High SchoolBurncoat HighBurncoat MiddleBurncoat Street PrepartoryCanterbury Magnet Computer BasedCanterbury Street SchoolCentral Mass PrepChallenge/Reach Middle / High SchoolsChandler Elementary CommunityChandler MagnetChandler Magnet Computer BasedChocksett Middle SchoolCity View DiscoveryClaremont AcademyClark Street Development LearningClinton Middle SchoolColumbus Park PreparatoryCrossroad (West Boylston)David Prouty High SchoolDavis Hill Elementary SchoolDevereux SchoolDoherty High SchoolDr Arthur Sullivan MiddleElm Park CommunityFlagg StreetFloral Street SchoolForest Grove Middle SchoolFrancis McGrath ElementaryGates Lane School of International StudiesGerald Creamer CenterGoddard School of Science and TechnologyGrafton StreetHarlow Street SchoolHartwell Learning CenterHeard Street Discovery AcademyHoly Name C.C. High SchoolHome SchoolJacob Hiatt MagnetKane Elementary School (Marlboro)Knox Trail Middle SchoolLake ViewLearning First Charter Public SchoolLeicester Memorial Elementary SchoolLeicester Middle SchoolLeominster High SchoolLincoln StreetMarion E. Zeh Elementary SchoolMassachusetts Academy of Math and Science at WPIMay StreetMcGrath SchoolMedway High SchoolMidland StreetMountview Middle SchoolNativity SchoolNelson PlaceNew Citizens CenterNorrback AvenueNorth High SchoolNorthbridge Middle SchoolNotre Dame AcademyOak Middle SchoolOur Lady of the Angels SchoolQuinsigamond SchoolRice SquareRobert F. Kennedy Lancaster SchoolRobert H. Goddard AcademyRoosevelt Elementary SchoolSaint Paul Diocesan Junior/Senior High SchoolSeven Hills Charter SchoolShepherd Hill Regional High SchoolShrewsbury High SchoolSky View Middle SchoolSouth High SchoolSouthbridge High SchoolSpirit of KnowledgeSt. John's High SchoolSt. Mary's SchoolsSt. Peter Central Catholic Elementary SchoolSt. Peter-Marian Junior-Senior High SchoolSullivan Middle SchoolSwanson Road Intermediate SchoolTantasqua Regional High SchoolTantasqua Regional Junior High SchoolTatnuck MagnetTEC Connections Academy Commonwealth Virtual School (TECCA)Thomas Prince SchoolThorndyke RoadThrive (New England Center for Children)Union HillUniversity Park CampusUxbridge High SchoolVenerini AcademyVernon Hill SchoolWachusett Regional High SchoolWawecus Road SchoolWest Boylston Middle/High SchoolWest Tatnuck SchoolWilson MiddleWoodbury Leadership AcademyWoodland AcademyWoodward Day SchoolWorcester AcademyWorcester Arts MagnetWorcester East Middle SchoolWorcester Seventh-day Adventist SchoolWorcester Technical High SchoolOther... School Name Other... Did you advance to next grade? * Yes No Current Grade * (as of date of application) - Select -PreK1st2nd3rd4th5th6th7th8th9th10th11th12thGraduatedDropped Out Student ID# * Type of School * Public Charter School Home School Private Parochial School Unknown Teacher(s) Name * Does Applicant speak another language other then English? * No Yes Medical Personnel InformationInsurance name and policy is required Insurance Name * Insurance Policy Number * Doctor’s Name * Doctor’s Phone * Emergency Hospital * Do you have a dentist? * Yes No Asthma * Yes No Details of Asthma List All Asthma Medications Bee Sting Allergies * Yes No Details of Bee Sting Allergies List All Bee Sting Allergies Medications ADD/ADHD * Yes No Details of ADD/ADHD List All ADD/ADHD Medications Learning Disability * Yes No Details of Learning Disability List All Learning Disability Medications Allergies * Yes No Details of Allergies List All Allergies Medications Physical Restrictions * Yes No Details of Physical Restrictions List All Physical Restrictions Medications Other Issues * Yes No Details of Other Issues List All Other Issues Medications Explain details of any physical, emotional or behavioral issues First Aid and CPR Parent/Guardian Signature I authorize the Boys & Girls Club of Worcester Staff that are trained in the basics of First Aid and CPR to give my child First Aid when appropriate and I give my permission to the Boys & Girls Club of Worcester to seek emergency medical treatment for minor child if I cannot be contacted. Will be responsible for all costs of medical attention and treatment. Signer Name *
