South Norwalk Public Library Girls Who Code Enrollment Form
Where: South Norwalk Public Library, 10 Washington St, Norwalk CT 06854
When: Saturday Mornings from 10:00 am to Noon
January 6th is an optional info session and project showcase hosted by current members
Jan 13, 20, 27; Feb 3, 10, 24; March 3, 10, 17, 24; Apr 7, 28; May 5, 12, 19.
This program is FREE. They will work in groups so we ask that girls plan to attend most weeks.

To enroll, please do ONE of the following:
1. Complete the form below (preferred) OR
2. Send the paper application, which can be found at www.amazinggirlsscience.com/programs/girls-who-code-club/. Mail it to: Saturday Academy Attn: Dr. Cynthia Barnett, P.O. Box 702, Norwalk CT 06854 OR
3. We will take walk-in registrations during our event on January 6th at 10 am at the South Norwalk Library

If you have any questions, please contact Dr. Cynthia Barnett: 203-855-9714, drcynthiabarnett@gmail.com

Child Name *
Your answer
Child Birth Date *
MUST be 10 or older
MM
/
DD
/
YYYY
Child Grade *
Must be in 6th-12th grade
Your answer
Child School *
Your answer
Home Address *
Your answer
Parent name *
Your answer
Parent Phone 1 and type (Cell/work/home) *
Your answer
Parent phone 2 and type (Cell/work/home)
Your answer
Parent email address *
Your answer
Additional emergency contact name *
Your answer
Emergency contact phone number *
Your answer
Does your daughter have an email address (Yes/No)? If Yes, what is it? *
Your answer
Please list any of your child's allergies, medications, or medical conditions we should be aware of
Your answer
Type your name and date below to agree to the following Voice, Likeness, and Comments Release: *
I give my permission to Saturday Academy Inc to use photographic images taken or likeness taken of my child in college publications, displays, marketing materials and website pages. I understand my child’s image may also be used in press releases and sent to news publications and other forms of print and digital media. I fully understand the intent of using my child’s likeness and /or comments, and in doing so do hereby relinquish any responsibility on the part of Saturday Academy Inc.
Your answer
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