Who We Are
- Our Team
- Board of Directors
- Corporators
- Alumni
- Club Impact
- Club Safety
- FAQ
What We Do
Find Your Club
Get Involved
- Donate
- Volunteer
- Become a Partner
- Careers
- Events
Our Stories

Biddeford Middle School: 21st Century Summer 2023

Biddeford Middle School 21st Century Community Learning Center Program

Summer 2023 Biddeford Middle School Member Registration Form

Member Name

Street Address

City

Member Email (if over 13):

Member Birthday

Ethnicity/Race

American Indian or Alaska Native

Asain

Black or African-American

Hispanic or Latino

Native Hawaiian or Pacific Islander

White

Some Other Race or Ethnicity

Two or More Races

Gender

Member lives primarily with: (check all that apply)

Mother

Father

Grandparent

Other Relative

Other Guardian

Primary Language at Home

Does Member know how to swim?

Yes

No

Medical Info

MEDICAL INFORMATION

Does the Member have any of the following medical conditions? (Check all that apply.)

ADD/ADHD

Asthma

Diabetes

Cerebral Palsy/Other Motor Condition

Epilepsy/Seizure Disorder

Emotional/Behavioral Disorder

NONE

Other Medical Conditions:

Does the Member have allergies or dietary restrictions?

Please check all the apply:

Bee Stings

Beef

Pork

Fish/Shellfish

Milk/Dairy

Peanuts

Penicillin

Tree Nuts

Wheat/Gluten

Please list any medications currently used by the member:

Does your child require transportation home?

Yes

No

School Info

SCHOOL INFORMATION

Grade Starting Fall 2021:

Fountas and Pinnell Reading Levels (if known)

SCHOOL COOPERATION RELEASE

SCHOOL COOPERATION RELEASE

As the Member's parent/guardian I give my permission to the Boys & Girls Clubs of Southern Maine to release the Member’s name listed on this application to their school in order to receive information regarding attendance, behavior in class and academic needs. The purpose of this is to help the organization do a better job of helping the member be successful in school, in the Boys & Girls Club and in life.

Yes

No

PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN INFORMATION

Parent/Guardian Name:

Parent/Guardian Phone

Parent/Guardian Email

Relationship to Member:

Mother

Father

Step Mother

Step Father

Aunt

Uncle

Sister

Brother

Cousin

Grandparent

Foster Parent

Other

Preferred Method of Contact:

Phone Call

Text Message

Email

Is the Parent/Guardian an Employee of Portland School Department?

Yes

No

Emergency Contact Name (if parent/guardian cannot be reached):

Emergency Contact Phone number:

Emergency Contact's Relation to Member

Optional Income Questions

Responses to the following four questions are critical to securing and maintaining funding for BGCSM. Your input is greatly appreciated. Your responses are confidential.

Thank you!

Is the member a resident of Maine and a citizen, U.S. National, legal alien, or permanent resident?

Yes

No

Does the member/family receive any of the following:

Free/Reduced price lunch

SNAP

TANF

Child Care Assistance

How many members in your household including yourself?

Annual Household Income:

PUBLIC RELATIONS RELEASE

PUBLIC RELATIONS RELEASE

PR TEXT

I give permission for the member listed on the application to have their name and/or pictures, portraits or such images, audio and/or video in advertising, news, social media, and/or any other promotional materials for Boys & Girls Clubs of Southern Maine (BGCSM), and for use or distribution in other non-BGCSM publications, electronic or otherwise, without notifying me. I waive any rights that I may have to inspect and/or approve the finished product that I or the member may have, including copyright. I agree to hold BGCSM harmless from any liability that may arise by virtue of any artistic or other distortion and/or alteration that may occur in the finished product.

PR Release

By checking this box I agree to the statement listed above,

PARENT/GUARDIAN AGREEMENT

PARENT/GUARDIAN AGREEMENT

Parent/Guardian Release

I hereby give my permission for my child to become a member of Boys & Girls Clubs of Southern Maine (BGCSM). I understand that BGCSM and its personnel are not responsible for personal injury or loss of property. I hereby give permission to BGCSM to secure proper treatment for my child in case of emergency. I understand that there is a BGCSM Parent & Member Handbook that provides guidelines my child and I must adhere to. I may request a copy of the handbook at any time.

By initialing below, I agree to submit my form responses.

MEMBER AGREEMENT

MEMBER AGREEMENT

I wish to become a member of Boys & Girls Clubs of Southern Maine. I promise to take care of my Club and its property, to allow no other person to have or use my card and to be loyal to my Club. I commit to being a positive member of my Club.

Thank you for contacting us.
We will get back to you as soon as possible.

Oops, there was an error sending your message.
Please try again later.

Stay Connected

Sign up for eNews!

Contact your neighborhood club

Auburn/Lewiston Clubhouse (Auburn)

Portland Clubhouse

Riverton Park Clubhouse (Portland)

Sagamore Village Clubhouse (Portland)

South Portland Clubhouse

Main Offices

277 Cumberland Avenue

PO Box 7830, Portland, ME 04112

info@bgcmaine.org

T: (207) 874-1069

F: (207) 874-1074

Charity Navigator Four Star Award for BGCSM

United Way Member Agency

MEMBER AGENCY

Share by: