Girls First and Last Name *

Phone Number *

Address

Age *

Grade *

School *

Birthdate *

Parent Guardian Name *

Parent Guardian Number *

parent email address *

teen email address or email to send zoom link:

How did you hear about girls inc.? *

In which programs will you be participating? *

My girl qualifies for *

Family Configuration *

Ethnicity *

Primary Language Spoken in the Home *

Residence Area *

Any immediate family members active duty military personnel ? *

Number of people living in household? *

Annual Household Income *

Please list any medical, physical or emotional conditions (including disabilities and Food Allergies) *

I hereby authorize Girl Inc. of the Island City, its agents and others working for it or on its behalf to use my daughter’s image/likeness/voice/artwork/writing in still photos, slides video productions, radio coverage, television coverage, interviews, testimonials and/or any other media purposes, including Girls Inc. of the Island City website, for promoting and representing Girls Inc. of the Island City and its programs, and do hereby grant and convey unto Girls Inc. of the Island City all rights, title, and interest in the above media including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings. (PARENT/ GUARDIAN: Please SIGN by typing NAME AND DATE)

I hereby authorize Girl Inc. of the Island City, its agents and others working for it or on its behalf to use my daughter’s image/likeness/voice/artwork/writing in still photos, slides video productions on Girls Inc. of the Island City’s accounts on social media sites (Facebook, Twitter, etc) including Girls Inc. of the Island City website, for promoting and representing Girls Inc. of the Island City and its programs, and do hereby grant and convey unto Girls Inc. of the Island City all rights, title, and interest in the above media including but not limited to, any royalties, proceeds, or other benefits derived from such photo-graphs or recordings. (PARENT/ GUARDIAN: Please SIGN by typing NAME AND DATE)

I hereby authorize, as parent or legal guardian, for to participate in Girls Inc. of the Island City Programs. In consideration for this participation, I do hereby, for myself and my heirs and assigns, release and agree to indemnify and hold harmless Girls Incorporated of the Island City, its employees and volunteers from all liability, loss, claim, demand, action or cause of action which arises or may arise or be occasioned in any way by such participation. I also release and hold harmless Girls Inc. of the Island City, its employees and volunteers from all liability, loss or claim which may occur in trans-porting my child for the purposes of participating in any Girls Inc. of the Island City activities. (PARENT/ GUARDIAN: Please SIGN by typing NAME AND DATE)