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

Black River Falls Program Info

$60/week or $15 daily per child
Monday-Friday from 7:30am-6:00pm
Monday, June 12th – Friday, August 18th

Chippewa Falls Program Info

$60/week or $15 daily per child
Monday-Friday from 7:30am-6:00pm
Monday, June 12th – Friday, August 18th

Eau Claire Program Info

$60/week or $15 daily per child
Monday-Friday from 7:30am-6:00pm
Monday, June 12th – Friday, August 18th

Altoona Program Info

$60/week or $15 daily per child
Monday-Friday from 7:30am-6:00pm
Monday, June 12th – Friday, August 18th

Menomonie Program Info

(Club hours complement the SDMA summer school schedule)
$35/week or $10 daily per child (half-day) / 1:00pm-6:00pm
$60/week or $15 daily per child (full day) / 7:30am-6:00pm
Monday, June 12th – Friday, August 18th

2023 Summer Program Registration

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

Altoona

Family Orientation Night: Thursday, June 8th, 2023*

Youth (grades 2-5) & teens (grades 6 & above). Please mark the session you will be attending at the Lunda Center as well as the number of people attending with you.

5:00pm

6:00pm

Number of people attending:*

Family Orientation Night: Wednesday, June 7th, 2023*

Youth (grades 2-5) & teens (grades 6 & above). Please mark the session you will be attending at the Chippewa Falls Center as well as the number of people attending with you.

5:00pm

6:00pm

Number of people attending:*

Family Orientation Night: Thursday, June 8th, 2023*

Youth (grades 2-5) & teens (grades 6 & above). Please mark ONE session you will be attending at the Lee & Mary Markquart Center as well as the number of people attending with you.

5:00pm

6:00pm

Number of people attending:*

Family Orientation Night: Wednesday, June 7th, 2023*

Grades 2nd-6th. Please mark ONE session you will be attending at the Menomonie Center as well as the number of people attending with you.

5:00pm

6:00pm

Number of people attending:*

Family Orientation Night: Thursday, June 8th, 2023*

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

5:00pm

6:00pm

Number of people attending:*

Member Name*

First Middle Last

Birth Date*

Gender*

Address*

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

Primary Phone*

Alternate Phone*

School*

Grade (as of Fall of the current year)*

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

Please select the dates your child will be attending:

Week 1: June 12-16

Monday June 12

Tuesday June 13

Wednesday June 14

Thursday June 15

Friday June 16

Week 2: June 19-23

Monday June 19

Tuesday June 20

Wednesday June 21

Thursday June 22

Friday June 23

Week 3: June 26-30

Monday June 26

Tuesday June 27

Wednesday June 28

Thursday June 29

Friday June 30

Week 4: July 5-7

We are closed Monday, July 3rd & Tuesday, July 4th.

Wednesday July 5

Thursday July 6

Friday July 7

Week 5: July 10-14

Monday July 10

Tuesday July 11

Wednesday July 12

Thursday July 13

Friday July 14

Week 6: July 17-21

Monday July 17

Tuesday July 18

Wednesday July 19

Thursday July 20

Friday July 21

Week 7: July 24-28

Monday July 24

Tuesday July 25

Wednesday July 26

Thursday July 27

Friday July 28

Week 8: July 31- August 4

Monday July 31

Tuesday August 1

Wednesday August 2

Thursday August 3

Friday August 4

Week 9: August 7-10

Monday August 7

Tuesday August 8

Wednesday August 9

Thursday August 10

Friday August 11

Week 10: August 14-18

Monday August 14

Tuesday August 15

Wednesday August 16

Thursday August 17

Friday August 18

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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Black River Falls Program Info

Chippewa Falls Program Info

Eau Claire Program Info

Altoona Program Info

Menomonie Program Info

2023 Summer Program Registration

Member Code of Conduct

Summer Program Agreement

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Summer Program Application Form

Black River Falls Program Info

Chippewa Falls Program Info

Eau Claire Program Info

Altoona Program Info

Menomonie Program Info

2023 Summer Program Registration

Member Code of Conduct

Summer Program Agreement

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