Test | Boys & Girls Club of the Sioux Empire

Child(ren) Information
Parent/Guardian Information
Emergency Contact & Authorized Pick-up
Household Information

Child 1 Information

General Information

Child First Name

Child Last Name

Age

Date of Birth

If child is not yet born, please select an anticipated birth date.

Sex M F Other

Race/Ethnicity American Indian or Alaskan Native Black or African American Native Hawaiian/Pacific Islander Asian Hispanic or Latino White Other

Child Lives With

Program & Care Information

Start Date

Days of Care Needed M T W TH F

Hours of Care Needed

Meals During Care Breakfast Lunch PM Sack

Please select the program you wish to have this child enrolled:

Infant, Toddler, and Two-Year-Old Full-time (4-5 Days) | $250 Part-time (1-3 Days) | $230

Location

Preschool and Pre-Kindergarten Program Full-time (4-5 Days) | $225 Part-time (1-3 Days) | $205

Location

For families looking to enroll in one of our Sioux Falls School District K-5 sites, please contact 605.338.8061.

K-5 After School Program Option 1: Full-time (4-5 Days) | $80/week Option 1: Part-time (1-3 Days) | $65/week Option 2: Full-time (4-5 Days) | $100/week - Extended care days are included in option 2 Option 2: Part-time (1-3 Days) | $87/week - Extended care days are included in option 2

Location

For families looking to enroll in one of our Sioux Falls School District sites, please contact 605.338.8061.

K-5 Before School Program Before School (select schools) | $36/week

Location

K-5 Summer Program Summer Care: Full-time (4-5 Days) | $175/week Summer Care: Part-time (1-3 Days) | $150/week

Location

K-5 Child is currently enrolled in

Next year, child will attend

Child T-shirt Size for K-5 only

Middle and High School Downtown Sioux Falls Community Youth Center | No Cost

Medical & Care Information

Physician's Name

Hospital

Physician Phone Number

Allergies

Does this child require any medication, medical device and/or other related care accommodations*?

Does this child have any physical/cognitive disabilities and/or other needs that require care accommodations*?

*If your child has a food allergy or intolerance, requires an EPI pen or other medication/medical device, or special accommodations a parent/guardian must complete additional documentation before use/adherence. These forms will be provided to you and kept in the child’s file. A family meeting may also be necessary to determine the best next steps for the child and the organization.

Child 2 Information

General Information

Child First Name

Child Last Name

Age

Date of Birth

If child is not yet born, please select anticipated birth date.

Sex M F Other

Race/Ethnicity American Indian or Alaskan Native Black or African American Native Hawaiian/Pacific Islander Asian Hispanic or Latino White Other

Child Lives With

Program & Care Information

Days of Care Needed M T W TH F

Hours of Care Needed

Meals During Care Breakfast Lunch PM Sack

Please select the program you wish to have the child enrolled.

Infant, Toddler, and Two-Year-Old Full-time (4-5 Days) | $250 Part-time (1-3 Days) | $230

Location

Preschool and Pre-Kindergarten Program Full-time (4-5 Days) | $225 Part-time (1-3 Days) | $205

Location

K-5 Before School Program Before School (select schools) | $36/week

Location

K-5 Summer Program Summer Care: Full-time (4-5 Days) | $175/week Summer Care: Part-time (1-3 Days) | $150/week

Location

K-5 Child is currently enrolled in

Next year, child will attend

Child T-shirt Size for K-5 only

Middle and High School Downtown Sioux Falls Community Youth Center | No Cost

Medical & Care Information

Physician's Name

Hospital

Physician Phone Number

Allergies

Does this child require any medication, medical device and/or other related care accommodations*?

Does this child have any physical/cognitive disabilities and/or other needs that require care accommodations*?

Child 3 Information

General Information

Child First Name

Child Last Name

Age

Date of Birth

If child is not yet born, please select anticipated birth date.

Sex M F Other

Race/Ethnicity American Indian or Alaskan Native Black or African American Native Hawaiian/Pacific Islander Asian Hispanic or Latino White Other

Child Lives With

Program & Care Information

Days of Care Needed M T W TH F

Hours of Care Needed

Meals During Care Breakfast Lunch PM Sack

Please select the program you wish to have the child enrolled.

Infant, Toddler, and Two-Year-Old Full-time (4-5 Days) | $250 Part-time (1-3 Days) | $230

Location

Preschool and Pre-Kindergarten Program Full-time (4-5 Days) | $225 Part-time (1-3 Days) | $205

Location

K-5 Before School Program Before School (select schools) | $36/week

Location

K-5 Summer Program Summer Care: Full-time (4-5 Days) | $175/week Summer Care: Part-time (1-3 Days) | $150/week

Location

K-5 Child is currently enrolled in

Next year, child will attend

Child T-shirt Size for K-5 only

Middle and High School Downtown Sioux Falls Community Youth Center | No Cost

Medical & Care Information

Physician's Name

Does this child have any physical/cognitive disabilities and/or other needs that require care accommodations*?

Does this child require any medication, medical device and/or other related care accommodations*?

Allergies

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