Girls Hearts on Fire
Program Enrollment 2020/2021
Club HOF
Oct-May
* Required
Student Information
Please complete this section on behalf of the student.
First Name & Last Name
*
Your answer
Name of School
*
Your answer
Grade
*
5
6
7
8
9
10
11
12
Is student Hispanic/Latino
Yes
No
Clear selection
Please Select all that apply.
*
Native American/American Indian/Alaska Native
Pacific Islander/Native Hawaiian
Black/African-American
Asian
White
Other:
Required
Qualifies Free or Reduced Lunch?
*
Yes
No
Student ID Number
Your answer
College Bound Scholar?
Yes
No
Clear selection
If student has been suspended; list how many times and why.
Your answer
Parent/Guardian& Household Information
Please complete this section on behalf of the parent or guardian
Parent/Guardian Full Name
*
Your answer
Home Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Home Phone
*
Your answer
Parent/Guardian Cell Phone
*
Your answer
Parent/Guardian Email
*
Your answer
Highest level of Education.
Some High School
High School Grad
Some College
College Grad
Masters/PHD Grad
Unknown
Clear selection
Languages spoken in the home.
Your answer
Program Permissions
Please complete each area for your child to participate in programming.
I agree to be added to Remind App for future communication
*
Yes
No
Required
I prefer my child attend program
*
Virtually
In-Person (Small Groups)
Drop-In to download School work (Use Wi-Fi)
Required
Program Evaluation Participation & Media Release
As part of Girls Hearts on Fire's efforts to make programming the best it can be, we engage in program evaluation activities. You and your child will occasionally be asked to give feedback on the program experience, through feedback forms (surveys), one-on-one conversations (interviews), or in group discussions (focus groups). This information will only be used to evaluate the program, and it will not affect your child in the program. Participation is always voluntary and you’re welcome to say no at any time. Please not that if you do not allow your student to participate in news and media activities, it will limit some (not all) of the evaluation participation.
I give permission for my child to be photographed for program purposes. As a participant in Girls Hearts on Fire programming, your child may have the opportunity to participate in media coverage for educational purposes. These opportunities may involve activities such as quotes attributed to your child, pictures of your child in the newspaper, on television, or in publications for the community. Additionally, photos, video, or your student’s work may be used by Girls Hearts on Fire or its partners.
*
Yes
No
Health Information
Please complete this section completely on behalf of the participant.
Allergies
Your answer
Any Medical Issues that we should be aware of? Including but not limited to Behavioral Considerations, Physical Limitations, Developmental Considerations.
Your answer
Preferred Hospital Network. In case of an emergency, staff will default to paramedics to make needed decisions. However, if given an option, please list your preferred hospital network:
Your answer
1st Emergency Contact Name, Relationship & Phone Number
Your answer
2nd Emergency Contact Name, Relationship & Phone Number
Your answer
Please initial the following statement to indicate understanding and agreement. In the event of an emergency involving my child, I understand that every effort will be made to contact me. If I cannot be reached in a timely manner, I hereby give Girls Hearts on Fire staff permission to act on my behalf in seeking emergency medical treatment for my child in the event that such treatment is deemed necessary by the GHOF staff. I give permission to those administering emergency treatment to do so. I absolve Girls Hearts on Fire and their staff and volunteers from liability in acting on my behalf in this regard.
Your answer
I am interested in my child attending the 4th Annual F.L.Y. Gala (Date TBD)
*
Yes
No
Maybe
There is a $50 Annual Membership Fee. Fee's will confirm your spot and are due no later than 9/21/2020
*
I am able to pay in full
I would like to apply for a partial scholarship.
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