Girls Clubhouse SUMMER 2023 Application
Summer Sessions: 
June 17, 2023 - July 29, 2023
10:00am - 11:30am
Every Saturday @ N.H Scott Recreation Center (2230 Tilson Road, Decatur, GA 30032)
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Email *
Youth First Name *
 Youth Last Name *
Parent/Guardian First and Last Name  *
Preferred Email Address *
Preferred Phone number *
Street Address *
City *
State *
Zip Code *
Youth Birthdate *
MM
/
DD
/
YYYY
Youth School *
City and State of School *
Current GPA *
Highest Grade Completed *
Youth Shirt Size *
Youth Race *
Youth Health Information (Medication, Special Conditions, Allergies, Dietary Restrictions, etc.)
Qualification Checklist
Emergency Contact Name
Emergency Contact Phone number
Emergency Contact Email Address
Essay Questions #1 : Why would you like to be apart of the Girls Clubhouse?
Essay Questions #2 : Describe some things that you would like to work on while you are in the program.
Essay Questions #3 : What are your long- term goals?
Essay Questions #4 : How can the Girls Clubhouse support your long term goals?
Photography / Videography Waiver *
I understand that my child may be photographed or recorded on video during the course of the leadership program. By checking the box below I provide consent for their image to be used in either print, electronic, or video form for the promotional and marketing use of the DeKalb County Office of Youth Services.
Required
Program Field Trip Transportation Waiver *
I give consent for my child to participate in the DeKalb County Office of Youth Services' Girls Clubhouse Program. I understand that transportation will only be provided for authorized field trips traveling from the designated departure location to the designated destination and returning to designated pick up location. In consideration for my child's participation in this program, by checking the box below, I do hereby personally, and on behalf of my child, absolve and release the DeKalb County Office of Youth Services and the Girls Clubhouse, staff and facilitators from any claim of personal injuries, damage to or loss of personal property, that might result during my child's participation in this program or transport to and from this program.
Required
Parent / Guardian Printed Name *
Parent / Guardian Signature (Type name again) *
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