Girls Inc. of the Central Coast Friendly PEERsuasion Phase 1 Program Application
Please complete the following information. Please note that there is a $10 fee for the Friendly PEERsuasion Phase 1 Power Program. https://www.paypal.com/cgi-bin/webscr?cmd=_s-xclick&hosted_button_id=MYE4BY8TWXA34
Last Name: *
First Name: *
Middle Name:
Mailing Address: *
Apartment Number:
City: *
State: *
Zip Code: *
Home Phone Number:
Cell Phone: *
School: *
Grade: *
Birthdate: *
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DD
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YYYY
Age: *
Ethnic Group:
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Race:
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Annual Household Income:
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Number of Family Members Living in Household:
Family Type:
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Primary Language Spoken at Home:
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Parents' Name: Mother's Full Name
Father's Full Name
How did you hear about this program?
PHOTO RELEASE
DISPLAYS, POSTER BOARDS, SLIDE SHOWS/POWER POINT *
I hereby grant permission to Girls Inc. of the Central Coast to publish photographs, video or other images taken of my daughter when participating in programs hosted by Girls Inc. for possible use in: DISPLAYS, POSTER BOARDS, SLIDE SHOWS/POWER POINT
PUBLICATIONS SUCH AS NEWSLETTERS AND ANNUAL REPORTS *
I hereby grant permission to Girls Inc. of the Central Coast to publish photographs, video or other images taken of my daughter when participating in programs hosted by Girls Inc. for possible use in: PUBLICATIONS SUCH AS NEWSLETTERS AND ANNUAL REPORTS
PROMOTIONAL VIDEOS/PUBLIC SERVICE ANNOUNCEMENTS *
I hereby grant permission to Girls Inc. of the Central Coast to publish photographs, video or other images taken of my daughter when participating in programs hosted by Girls Inc. for possible use in: PROMOTIONAL VIDEOS/PUBLIC SERVICE ANNOUNCEMENTS
NEWSPAPER ARTICLES *
I hereby grant permission to Girls Inc. of the Central Coast to publish photographs, video or other images taken of my daughter when participating in programs hosted by Girls Inc. for possible use in: NEWSPAPER ARTICLES
WEBSITE CONTENT *
I hereby grant permission to Girls Inc. of the Central Coast to publish photographs, video or other images taken of my daughter when participating in programs hosted by Girls Inc. for possible use in: WEBSITE CONTENT
Relationship of person signing to participant in photograph:
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Payment Method: *
Link to pay will appear once this form has been submitted.
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