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Girls Inc. After School Enrichment Registration Form 2024-2025

Empower Your Daughter with Girls Inc. TN Valley's After School Program!

At Girls Inc. TN Valley, we believe in nurturing the potential of every girl. Our after school program provides a safe, supportive, and inspiring environment where your daughter can:

- Form lasting friendships with girls who share her interests
- Discover and develop her unique talents and skills
- Engage in hands-on, girl-centered activities that foster confidence and self-expression
- Learn from positive role models and mentors who encourage her to dream big

Through our research-based programming, your daughter will explore topics such as STEM, health and wellness, financial literacy, and leadership development. She'll have the opportunity to participate in exciting projects, field trips, and community service initiatives that will help her grow into a strong, smart, and bold young woman.

Don't miss this chance to invest in your daughter's future! Register now for Girls Inc. TN Valley's After School Program and watch her thrive.

For more information or if you have any questions, please contact our Program Director, Meghan Bowers mbowers@girlsinctnv.org or call 865-482-4475. We look forward to welcoming your daughter to our empowering community of girls!
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Participant Name: *
Participant Date of Birth: *
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Participant Grade: *
Participant Age: *
Ethnicity/Race: *
Required
Child(ren) lives with:
 *
Required
School Child Attends *
Participant Address: *
Street Address, City, State, Postal Code
Parent/Guardian Name: *
Cell Phone Number: *
E-mail Address: *
Address (if different from child):
Emergency Contact Information:
Please make sure this person is different from the parent/guardian listed above. Listing someone as an emergency contact also allows for them to be a backup for pick up for after school, as well as during emergencies. Please only list people that you would allow to pick up your child from after school.
Emergency Contact #1 Name: *
Relationship to Child

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Cell Phone Number: *
Alternate Phone Number:
Emergency Contact #2 Name: *
Relationship to Child *
Cell Phone Number: *
Alternate Phone Number:
Additional Emergency Contact:
Additional Emergency Contact Phone #:
Medical Information
Please list any allergies, medical diagnoses, or behavioral concerns that our staff should be aware of before your child attends camp. This will prepare our staff to ensure your child has the best experience possible.
Does your child have any allergies, chronic illnesses, or medical conditions? If yes, please describe.
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Does your child have any specific food restrictions?
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Does your child have any behavioral needs that our staff should be aware of? If yes, please describe.
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After School Information
Please indicate if there are any variances in your child(s) attendance to ASP (ex: only coming 2x per week, only coming every other week, only on Wednesday's etc.)
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Photo/Media Release: 

I will permit photos and/or videos of my child to be taken in connection with Girls Inc. activities. I also understand that some of these photos may be used in marketing materials, social media sites (Facebook, Instagram, etc.), on the Girls Inc. website, and partner-related media sites and/or for purposes related to Girls Inc. programming. 

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Authorizations
Please read these descriptions in their entirety before signing.

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Girls Inc. during the after school program. In exchange for the acceptance of said child’s candidacy by Girls Inc., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Girls Inc. of the Tennessee Valley, and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from after school sessions.

In case of injury to said child, I hereby waive all claims against Girls Inc. of the Tennessee Valley. including all affiliates. There is a risk of being injured that is inherent in all activities. Some of these injuries include, but are not limited to, the risk of fractures/paralysis.

Medical Authorization and Consent Agreement

I authorize Girls Inc staff including: Coaches, team parents, and/or other officials of Girls Inc., as well as the above-identified Emergency Contacts to administer basic and temporary first aid to my child if necessary. In the event of a serious injury I give Girls Inc. permission to transport my child to a hospital or other emergency facility to receive emergency medical treatment. I also authorize ambulance/rescue squad attendants to administer such treatment as is medically necessary and I authorize licensed health practitioners working in the hospital or emergency medical facility to examine and provide emergency medical treatment to my child if warranted. I also agree to accept full financial responsibility for any injury that my child may incur as a result of her participation. I further agree to release from and to indemnify for any liability, now and hereafter, for any injury my child may incur as a result of her participation in the Program Activity, Girls Inc. of TNV , their employees, officers, and volunteers. I make this agreement on behalf of my heirs, my estate and myself. I understand that Girls Inc. personnel will contact me as soon as possible regarding any emergency involving my child.

Other Authorizations

I understand that Girls Inc. is not a licensed daycare but is a National Youth Serving Organization that offers research-based programs for children and teens, specifically girls. I understand that Girls Inc. of Tennessee Valley may conduct research about the impact of its programs for testing and other evaluation efforts. All information regarding girls or their participation in programs will remain confidential.

Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM ACKNOWLEDGING AND AGREEING TO THE ABOVE STATEMENTS. I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
By typing your name in the box below, you are electronically signing that you have completed and understand the information in this form. *
Would you like to receive the monthly Girls Inc. of TNV E-Newsletter?
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SSBOS Survey (5-18 years old)

As part of a larger initiative, Girls Inc of the TN Valley takes part in the Strong, Smart, & Bold Outcomes Survey. The survey will take place at Girls Inc. organizations across the United States and Canada. During the survey, girls will be asked questions about topics such as nutrition and physical activity, school engagement and grades, relationship skills, and their experience at Girls Inc. The survey takes 20 minutes to complete.

The survey has been designed to be taken online, and will pose little to no risks to your child(ren). Girls will not put their names on the survey, and no one at Girls Inc of TN Valley will see girls' individual answers. Your childs' survey answers will be added to those from other chidren's surveys so that we can better understand what Girls Inc. is like for them and for other girls across the United States. No individual child or organization will ever be mentioned by name when reporting results. All information from the survey is being used to assess the well-being of Girls Inc. members and will be kept completely confidential.

The results of the survey will help your child(ren) and other Girls Inc girls in the future by assisting the National Girls Inc. organization to develop programming that best meets girls' needs. We would like all selected girls to take part in the survey, but the survey is completely voluntary and no one is required to participate. Girls may answer some, none, or all of the questions. Girls may also stop taking the survey at any point. Review copies of the survey are available to you with staff members at your local Girls Inc. If you would like to see the survey, a copy will be provided to you. If you have any additional questions or concerns about the survey, please contact Meghan Bowers, Program Director, mbowers@girlsinctnv.org.

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I agree to pay the $20 membership fee for my child(ren) if I have not already paid it for this year. 

The membership fee is a required fee for securing a spot, and only has to be paid once a year. If your child is already signed up for previous camps, sports, or ASP this year, you have already done this.
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After School Fees are $55/child/week. There are limited scholarships available. Scholarships will be given on a first come first serve basis. If you do not receive a scholarship, payments for ASP will need to be made before the beginning of each week. Invoices for each week of ASP will be sent out through your email before the beginning of each week. Please email lmanning@girlsinctnv.org if you have any further questions about payment. You may also email tobrien@girlsinctnv.org for questions about invoices, or payment options.
I recognize that scholarships are limited for ASP. I also recognize that if I do not receive a scholarship, I will be responsible for paying the entire fee before the beginning of each week of ASP. 
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Scholarship Information
In order to apply for scholarship, please email mbowers@girlsinctnv.org with a form of proof of income (including a W2, two most recent paystubs, federal assistance paperwork, or a billing statement.) If you are applying for a scholarship, please answer all of the following questions in order to qualify. 
I will need/be applying for a scholarship. I will provide information of proof of income in order to qualify.
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FAMILY INCOME: All sources of income in the household must be noted on the application. In order to receive aid, valid proof of one of the following must be provided: Last two pay stubs or a W2, Unemployment Stub, or Disability Papers.
Clear selection
Are you currently recieving food stamps?
Clear selection

Is your child(ren) recieving Free/Reduced Lunch?

Clear selection

Are you currently receiving Family First/Tenn Care?

Clear selection

Are your membership dues current?

Clear selection

Have you volunteered time to Girls Inc? If no, please explain.

If you will be applying for a scholarship for ASP, please indicate which level you will be applying for: *

Are there any circumstances that Girls Inc. should be made aware of? (i.e. Child custody negotiations, orders of protection, etc.)

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Parent/Guardian Electronic Signature *
Today's Date *
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