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Before & After School

After School Program

Age Restriction:  6th, 7th and 8th grade

Boys & Girls Club Unit:
Fees and Attendance
Acknowledgment of Fees and Attendance Notice
Anticipated Start Date
Anticipated Schedule:
Please indicate what days you anticipate your child will attend the program.

MEMBER INFORMATION

The following information is required for membership at Boys & Girls Clubs of Hernando County.

This information will not be used individually but grouped and used for securing and maintaining local, state, and federal funding sources, including donations and grants. All information is held strictly confidential.

Please enter the following information for the Child you are enrolling as a Member of the Boys & Girls Clubs of Hernando County:

 

First Name
Middle Name
Last Name
Date of Birth:
Gender:
Racial Identity
Ethnicity: Is Member Hispanic or Latino?
(Hispanic or Latino is a person of Cuban, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.)
Primary Language Spoken in Home:
Address:
City:
State:
Zip Code:

SCHOOL INFORMATION FOR 2024-2025 SCHOOL YEAR

 

School:
Grade:
Does member participate in any Education Programs
Does member participate in any Education Programs
Is Member Eligible for Free or Reduced Lunch?

MEDICAL INFORMATION

 

Doctor's Name and Telephone Number
Please enter your initials indicating your agreement and understanding of the Authorization for Medical Care
Initials indicate my agreement and understanding of the Authorization for Medical Care.
Insurance Coverage
If Private, Insurance Company name
Has Member been diagnosed with any of the following conditions:
Check all that apply
Has Member been diagnosed with any of the following conditions:
Does Member have any other Serious Medical Issues, including dietary restrictions and/or allergies?
If yes, please describe
This list should include all known allergies, including food allergies
Is Member currently on any medications?
If yes, please list
If medications are to be given during Program Hours you must complete an Authorization for Prescription and Non-Prescription Medication form.
Has member had experience in the following:
Has member had experience in the following:

PHYSICAL INFORMATION

Eye Color
Hair Color
Skin Color/Features:
Height:
Weight:

HOUSEHOLD INFORMATION

Member Lives With...
Approximate only
Annual Household Income
Do you receive vouchers from the housing authority or live in public housing?
Number in Household:
Is there a Member of the Household 65 years old or older?
Is there an Adult Member(s)of the Household with a disability?
Current Head of Household
Is Member from a Single Parent Household:
Military: Household member currently enlisted or have served
Military: Household member currently enlisted or have served
Is Member impacted by parent/caregiver serving in the military?
Is Member impacted by parent/caregiver serving in the military?
If yes, please indicate whether Active or Reserve and What Branch
Has a parent/guardian in the Member’s household been incarcerated at any point?
Has a parent/guardian in the Member’s household been incarcerated at any point?
Does anyone in the Member’s household have or previously had any gang affiliations?
Does anyone in the Member’s household have or previously had any gang affiliations?
Does anyone in the Member’s household have experience with drug or alcohol abuse?
Does anyone in the Member’s household have experience with drug or alcohol abuse?
Has anyone in the Member’s household had an experience with Human Trafficking?
Has anyone in the Member’s household had an experience with Human Trafficking?

Please note that if there is a court order pertaining to a parent/guardian and contact with a member, you MUST provide a copy of the court order to the Unit Director.  We cannot, by law, restrict access to a child by a parent without a valid court order.  You may upload a copy of a court order using the upload button below, prior to submitting your application.

*Primary Contact Name:
The primary contact will be the first person contacted with any concerns regarding member, member's account or in an emergency. The primary contact is the only person who may make changes to Member's account information, including pick-ups/emergency contacts.
Relationship to Member:
Information/Permissions
Select all that apply:
Home Phone:
Work Phone:
Cell Phone:

Information/Permissions
Select all that apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Information/Permissions
Select All That Apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Information/Permissions
Select All That Apply:
Home Phone:
Work Phone:
Cell Phone:
EMail:

Terms & Conditions - PLEASE READ THIS COMPLETELY AND CAREFULLY
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