CC's Little Village Boys & Girls Club Membership

Boys & Girls Clubs of Chicago will be offering out-of-school programming beginning September 7, 2021, and will take place Monday through Friday from 2:30-6 p.m. for K-6th grade and 2:30-8 p.m. for 7th-8th grade. The safety of our members is of the utmost importance to us, and programs will run in accordance with CDC guidelines and protocols.

You may submit an application through the online membership form available below or by scheduling an appointment with your Club Director to pick up a form. To schedule an appointment to pick up a form, please either call 773-277-1800 or email arivera@bgcc.org and mpadilla@bgcc.org.

Please note that by submitting an application, it does not guarantee your child a spot at our Club. You will be notified if a spot is available for your child. At that time, you will be asked to complete additional steps to confirm your child’s registration. Details for this year include:

- Membership is $20 per child
- All Club participants will be required to wear a mask while at the Club that will be provided by the Club daily
- All Club participants must comply with safety requirements and social distancing protocols
- Parents must provide contact information including phone and email and join the Remind App
- All Club participants must attend Fall Program in good health. If a child presents any symptoms of illness, the child will be isolated and a parent will be called to take the child home

Thank you for your interest in the Club’s out-of-school program.

Step 1 of 2

CC's Little Village Club Membership Application
Privacy: Any personal information requested of you is for BGCC's records and for required reports related to the funding our Organization receives. The answers you provide will be kept private to the greatest extent possible and will only be used in the event it is necessary for reporting purposes (such as for grant funding) at which point the information will be reported anonymously to the greatest extent possible. Your cooperation in providing this information is both appreciated and necessary. Required fields are denoted with asterisks.
Member Information
Child's Name (required)*
First Last
Child's Phone Number (if applicable)
Can we text your child (if applicable)?
Child's Gender (required)*
Child's Birthdate (required)*
Child's Race (required)*
Child's Ethnicity (required)*
Child's School (required)*
Child's Grade (required)*
School ID #
Member Status (required)*
Head of Household Information
Parent/Guardian Name (required)*
First Last
Address (required)*
Street Address City State ZIP Code
Preferred Email Address (required)*
Parent/Guardian Mobile Number*
Parent/Guardian Home Number
Parent/Guardian Work Number
Can we send you updates/announcements via text message? (required)*
Relationship (required)*
Family Size (required)*
Family Income (required)*
Secondary Parent/Guardian Information
Parent/Guardian Name (required)*
First Last
Address (required)*
Street Address City State ZIP Code
Parent/Guardian Mobile Number (required)*
Parent/Guardian Home Number
Parent/Guardian Work Number
Relationship (required)*
Household Type (required)*
Family Setting (required)*
Check all that apply (required)*
- TANF
- Food Stamp
- Medicaid
- School Lunch Program
- SSDI
- SSI
- None
Medication Information
*Staff are not allowed to administer medication. Please speak to the Club Director about completing the Special Care Needs Form if appropriate.
Medications (if applicable)
Medical Problems/Allergies (if applicable)
Does your child have any special needs?
Does your child participate in school IEP?
Please list any disabilities your child may have (if applicable)
Emergency Contacts
Emergency Contact #1 (required)*
First Last
Emergency Contact #1 Phone Number (required)*
Relation to child (required)*
Emergency Contact #2 (required)*
First Last
Emergency Contact #2 Phone Number (required)*
Relation to child (required)*

CPS Students
Boys & Girls Clubs of Chicago (BGCC) will gather data to evaluate the Club’s progress toward meeting Club program objectives, analyze areas of potential program improvement, and better communicate impact to parents, donors, and the community. In particular, BGCC will gather member data to determine how Club attendance makes an impact in several areas, including academics, character, and health. A portion of this analysis will be done utilizing student information from Chicago Public Schools (CPS). With my permission, BGCC would like to collect the following information from my child’s CPS school records through the current school year. Grade Level, Grades, Standardized Achievement Test Scores, Attendance Information, and Number of Days Suspended. This data will be collected on a periodic basis using my child’s CPS student ID number, analyzed against BGCC attendance data, and then reported for the Club as a whole. These reports may be used internally for program improvements or communicated externally to the community, youth, parents, and existing or potential donors and funders. Member information will remain strictly confidential and will only be used by BGCC, its staff, and long-standing technology partner nFocus Software. Strict guidelines are in place to ensure confidentiality and each party has received appropriate training. At no point will individual student data be publicly released.
CPS Data Consent (required)*
Virtual Club Consent
In an effort to continuously serve members during the Club closure, Boys & Girls Clubs of Chicago is providing virtual programming for Club members, through which Club staff will facilitate program activities through online platforms. Boys & Girls Clubs of Chicago will use software, tools and applications provided by third parties that members, parents/guardians and/or staff will access via the Internet and use for purposes of communication and programming. These platforms include Facebook, YouTube, Zoom, Instagram, and Tik Tok. I give my consent for my child to utilize these platforms for distance-based, virtual Club program purposes. Please be aware that each application collects different information about its users and has its own privacy terms and conditions to which members must adhere. Please review these carefully before registering your member. Our commitment to keeping the young people we serve safe is always our number one priority. Boys & Girls Clubs of Chicago will actively monitor online member activity while engaged with us and will make every effort to protect member information by, among other things, maintaining control of, and access to, the data collected; prohibiting re-disclosure of member information; limiting the purposes for which the online platforms may use member information; ensuring there is no advertising and that no member information is collected for commercial purposes. Further, all activities online must comply with Boys & Girls Clubs of Chicago’s safety policies, including the Social Media Policy, One-on-One Contact Policy, and Internet Safety Policy.
Parent or Guardian Consent (required)*
I agree to Boys & Girls Clubs of Chicago's Virtual Club membership consent policy.
Membership Consent
I have read the completed application, understand the rules of Boys & Girls Clubs of Chicago (BGCC), and request that my son/daughter be admitted into membership. I have explained the rules to my son/daughter and agree that BGCC will not be responsible for any accident to the boy/girl while on the premises or while engaged in any activities away from BGCC. I give my consent for the publication and use of photographs and/or video footage in which my son/daughter may appear or say, to be used in any way BGCC may care to use them including social media, without limitations or reservation, as deemed appropriate by the organization. I fully understand that I will receive no remuneration as a result of any use of photographs and/or videos. I also allow my child to participate in the annual outcome measurement tool kit survey and for BGCC to receive my child’s grades and test scores from their school. I also allow BGCC to include my child in focus groups conducted by internal staff members or by consultants working on behalf of BGCC, for the purpose of obtaining youth feedback and insight. I give my consent for BGCC to provide transportation for my child/teen for field trips.
Parent or Guardian Consent (required)*
I agree to Boys & Girls Clubs of Chicago's membership consent policy.
Parent or Guardian Digital Signature (required)*
First Last
Member's Digital Signature (required)*
First Last

CC's Little Village Boys & Girls Club Membership

Step 1 of 2

CC's Little Village Club Membership Application

Member Information

Head of Household Information

Secondary Parent/Guardian Information

Medication Information

Emergency Contacts

CPS Students

Virtual Club Consent

Membership Consent