Please fill out our After school program registration Our After School Program Starts on September 27th. General Information (One Application Per Child)Which site are you registering for? Columbus Avenue Clubhouse Previous/Current Member of BGC New Haven? Yes No Member of the club for how many years12345otherOther Name* Child's First Name Child's Last Name Preferred Name Age* Gender:*MaleFemaleNon-BinaryOtherOther Date of Birth* MM slash DD slash YYYY Race/Ethnicity:*American Indian or Alaska NativeAsianBlack or African AmericanHispanic/LatinoNative Hawaiian/Other Pacific IslanderWhiteTwo or More RacesOtherOther Child Lives With*Mother OnlyFather OnlyFoster Care1 Parent/1 Step2 ParentsGrandparentsOtherOther Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Grade/Year*K1st2nd3rd4th5th6th7th8th9th10th11th12thSchool*Achievement First Amistad High SchoolAmistad Academy Elementary SchoolAmistad Academy Middle SchoolAugusta Lewis Troup SchoolBarack H. Obama Magnet University SchoolBarnard Environment Studies Interdistrict Magnet SchoolBenjamin Jepson MagnetBetsy Ross Arts MagnetBishop Woods Architecture & Design MagnetBooker T Washington AcademyBrennan Rogers School of Communication and MediaCelentano SchoolClemente Leadership AcademyClinton Avenue SchoolCommon Ground High School, Urban Farm and Environmental Education CenterConte West Hills SchoolCooperative Arts and Humanities High SchoolDavis Academy for Arts and Design InnovationDr. Reginald Mayo Early Learning CenterEast Rock SchoolEdgewood SchoolElm City College Preparatory Elementary SchoolElm City MontessoriEngineering & Science University Magnet SchoolFair Haven SchoolFamily Academy of Multilingual ExplorationGateway To CollegeHighville Charter SchoolHigh School In The CommunityHill Central Music AcademyHill Regional Career MagnetHyde Leadership SchoolJames Hillhouse High SchoolJohn C Daniels School of International CommunicationJohn S Martinez Sea & Sky STEM Magnet SchoolKing Robinson Interdistrict Magnet SchoolLincoln Bassett SchoolLW Beecher Museum School of Arts & Sciences Interdistrict MagnetMauro Sheridan Science, Technology & Communications SchoolMetropolitan Business AcademyNathan Hale SchoolNew Haven Academy MagnetRiverside AcademyRoss Woodward ClassicalSound SchoolTruman SchoolWexler Grant SchoolWilbur Cross High SchoolWorthington Hooker SchoolOtherOther Neighborhood District (Please Select One):*AmityAnnexBeaver HillsBeaver HillsDixwellDowntownDwightEast RocKEast ShoreEdgewoodFair HavenFair Haven HeightsHillLong WharfNewhallvilleProspect HillQuinnipiac MeadowsWest RiverWestvilleWooster Square/Mill RiverOutside of New HavenSchool District* New Haven Public Schools Other Head of Household Information:Primary Parent/ Guardian* Parents First Name Parents Last Name Relationship to Child* Check all that apply:* Primary Emergency Contact Authorized to Pick Up Interested in BGCNH Volunteer opportunities.* Yes No Best # to reach you.* Home Cell Work Home Phone*Mobile Phone*Parent/Guardian Email Address* Employer: Job Title: Work PhoneAddress is the same as above (Applicant's/ Child's)* Yes No Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Other Parent/Guardian: Parent/ Guardian Name Parent First Name Parent First Name Relationship to Child Check all that apply: Primary Emergency Contact Authorized to Pick Up Best # to reach you. Home Cell Work Interested in BGCNH Volunteer opportunities. Yes No Home PhoneMobile PhoneParent/Guardian Email Address Employer: Job Title: Work PhoneSame as address above (Applicant's/ Child's)* Yes No Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Confidential Information: The following information is necessary for our records and the funding our organization receives. The answers you provide are confidential. Your cooperation in providing this information is both appreciated and required.Annual Household Income:*0-10,00010,001 – 20,00020,001 – 30,00030,0001 – 40,00040,0001 – 50,00050,000 or more Number of Family Members in the Household:*Please enter a number from 1 to 20.Check All That Apply:* SSDI SSI TANF Food Stamps Medicaid Veteran Compensation None Emergency Contact*List at least one other person other than a parent/ guardianEmailThis field is for validation purposes and should be left unchanged.