Boys & Girls Clubs of the Greater Chippewa Valley » Summer Program Application Form

General Summer Program Info

$60/week or $40 punch card for those attending 1-3 days per week, card expires weekly.
Monday-Friday from 7:30am-6:00pm
Monday, June 16th – Friday, August 22rd

Menomonie River Heights: When River Heights Summer School is in session, the Club will only be open for half-day programming, beginning at 1pm and the weekly fee rate is $35/week or $20 punch card for those attending 1-3 days per week, card expires weekly.

Please complete one form per child.

Step 1 of 3

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Which club are you attending?*

Black River Falls

Chippewa Falls

Eau Claire

Menomonie - River Heights

Altoona

Family Orientation Night: May 29th or June 3rd, 2025*

Please mark the session you will be attending at the Lunda Center as well as the number of people attending with you.

May 29 at 5:30 pm

June 3 at 5:30 pm

Number of people attending:*

Family Orientation Night: May 27th or June 9th, 2025*

Please mark the session you will be attending at the Chippewa Falls Center as well as the number of people attending with you.

May 27 at 6:30 pm

June 9 at 5:30 pm

Number of people attending:*

Family Orientation Night: May 28th or June 12th, 2025*

Please mark ONE session you will be attending at the Lee & Mary Markquart Center as well as the number of people attending with you.

May 28 at 6:30 pm

June 12 at 5:30 pm

Number of people attending:*

Family Orientation Night: June 3rd or June 10th, 2025*

Please mark ONE session you will be attending at the Menomonie River Heights Center as well as the number of people attending with you.

June 3 at 6:00 pm

June 10 at 5:30 pm

Number of people attending:*

Family Orientation Night: May 29th or June 11th, 2025*

Please mark the session you will be attending at the Altoona Center as well as the number of people attending with you.

May 29 at 6:00 pm

June 11 at 5:30 pm

Number of people attending:*

Member Name*

First Middle Last

Birth Date*

YYYY

Gender*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Primary Phone*

Alternate Phone*

School*

Grade (as of Fall of the current year)*

Would you to receive a scholarship application?

Yes, please.

No, thank you.

School ID #*

Parent/Guardian Name*

First Last

Daytime Phone*

Email*

Second Parent/Guardian Name*

First Last

Daytime Phone*

Email*

Emergency Contact Name*

First Last

Daytime Phone*

Doctor's Name

Clinic

Phone

Please list special needs, allergies, or health concerns

REQUIRED! Please select the dates your child will be attending:

Week 1: June 16-20

Monday, June 16

Tuesday, June 17

Wednesday, June 18

Thursday, June 19

Friday, June 20

Week 2: June 23-27

Monday, June 23

Tuesday, June 24

Wednesday, June 25

Thursday, June 26

Friday, June 27

Week 3: June 30-July 3

We are closed Friday, July 4th

Monday, June 30

Tuesday, July 1

Wednesday, July 2

Thursday, July 3

Week 4: July 7-11

Monday, July 7

Tuesday, July 8

Wednesday, July 9

Thursday, July 10

Friday July, 11

Week 5: July 14-18

Monday, July 14

Tuesday, July 15

Wednesday, July 16

Thursday, July 17

Friday, July 18

Week 6: July 21-25

Monday, July 21

Tuesday, July 22

Wednesday, July 23

Thursday, July 24

Friday, July 25

Week 7: July 28 - August 1

Monday, July 28

Tuesday, July 29

Wednesday, July 30

Thursday, July 31

Friday, August 1

Week 8: August 4-8

Monday, August 4

Tuesday, August 5

Wednesday, August 6

Thursday, August 7

Friday, August 8

Week 9: August 11-15

Monday, August 11

Tuesday, August 12

Wednesday, August 13

Thursday, August 14

Friday, August 15

Week 10: August 18-22

Monday, August 18

Tuesday, August 19

Wednesday, August 20

Thursday, August 21

Friday, August 22

Member Code of Conduct

As a Member of the Boys & Girls Club I will:

Be respectful: I will respect myself, the staff, my Club, and its members.
Give My Best Effort: I will give my best effort, make good choices, and strive for a positive, caring attitude.
Follow Directions: I will listen to the staff and follow directions. I will not be in rooms when there is not a staff present.
Be Honest: I will be honest with the staff and my fellow members. If I see something that isn’t right, I will tell the staff.
Take Part In Programs: During programming, I will choose a program and give it my best effort.
Have Fun: I will give my best effort to make each new day at the Club the best it can be.

Member Signature*

Date*

MM slash DD slash YYYY

Summer Program Agreement

I, the parent or guardian, of this Club member agree to the following:

I have read and agree to the following terms:*

Please check all.

I will notify the Boys & Girls Club of days that my youth will not be in attendance a minimum of 24 hours in advance..

I will pay fees on time. If I do not make a payment on time, I understand that my child will not be able to attend the Club until the past due balance has been paid.

I will work with the staff at the Boys & Girls Club to ensure a positive experience for my youth this summer and will call or talk to the Center Director if problems or concerns arise.

I have read the Great Futures Guide and agree to the policies, procedures and behavior guidelines outlined.

I understand that if there is a behavioral issue with my child on any day he/she is attending, it is my responsibility to pick up my child or provide an alternate responsible party to pick my child up within 30minutes after being contacted by a staff member.

Parent/Guardian Signature*

Date*

MM slash DD slash YYYY

5 + 3 =*

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2025 Summer Registration

General Summer Program Info

Member Code of Conduct

Summer Program Agreement

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Summer Program Application Form

General Summer Program Info

Member Code of Conduct

Summer Program Agreement

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