Boys & Girls Club of Greater Santa Rosa

Note: You are registering for the Boys & Girls Club of Greater Santa Rosa located at 1011 Hahman Drive Santa Rosa, CA 95405

Form Progress: 1 / 3

1 2 3

Registration Type *

Member Information

Child's name *

First Name

Last Name

Primary phone *

Address *

Street Address

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Child's Birthdate *

Gender *

School your child attends

Grade (Most Recently Completed for Summer Registration) *

Members must be 5 years old and enrolled in Kindergarten for the school year to attend. No TK.

Returning member?

Are you requesting van pick up from school? *

Specify school if registering for after school transportation

Do you receive any of the following? Check all that apply. *

Estimated Enrollment *

Special Needs (IEPs); Known Allergies, Illnesses, or Injuries; Medications