Membership Membership $50 - Per Participant $80 - Per Family Already a Member No Membership Subsidy

Child First Name

Last Name

Date Of Birth (MM/DD/YYYY)

School

Grade

In order for Girls Inc Staff to provide the best support, please disclose all relevant information in order for us to appropriately meet their needs i.e. Allergies, Diagnosis (ADHD, Behavioural, Anxiety, ODD), Physical limitations, changes at home(separation, divorce, death), history of trauma/abuse/foster,etc.:

Girls Inc. Programs ($20 for Members. $50 for Non-Members) Girls Inc. Programs ($20 for Members. $50 for Non-Members) Girls CLUB (Ages 6-8) Monday 4-5:30 pm [Virtual] Girls SQUAD (Age 9-12) Monday 4-5:30 pm [In-Person] Girls SQUAD (Age 9-12) Tuesday 4-5:30 pm [Virtual] Girls GROUP (Age 12-16) Tuesday 4-5:30 pm [In-Person] Girls GROUP (Age 12-16) Wednesday 4-5:30 pm [Virtual] Girls CLUB (Ages 6-8) Wednesday 4-5:30 pm [In-Person] BOOK CLUB (Ages 6-9 *All ages are welcome*) Thursday 4-5:30 pm [Virtual] BOOK CLUB (Ages 6-9 *All ages are welcome*) Thursday 4-5:30 pm [In-Person]

Total Fees for Child 1 (For subsidy input "subsidy")

Child#2 First Name

Child #2 Last Name

Date Of Birth

In order for Girls Inc Staff to provide the best support, please disclose all relevant information in order for us to appropriately meet their needs i.e. Allergies, Diagnosis (ADHD, Behavioural, Anxiety, ODD), Physical limitations, changes at home(separation, divorce, death), history of trauma/abuse/foster,etc.:

School

Grade

Girls Inc. Programs ($20 for Members. $50 for Non-Members) Girls Inc. Programs ($20 for Members. $50 for Non-Members) Girls CLUB (Ages 6-8) Monday 4-5:30 pm [Virtual] Girls SQUAD (Age 9-12) Monday 4-5:30 pm [In-Person] Girls SQUAD (Age 9-12) Tuesday 4-5:30 pm [Virtual] Girls GROUP (Age 12-16) Tuesday 4-5:30 pm [In-Person] Girls GROUP (Age 12-16) Wednesday 4-5:30 pm [Virtual] Girls CLUB (Ages 6-8) Wednesday 4-5:30 pm [In-Person] BOOK CLUB (Ages 6-9 *All ages are welcome*) Thursday 4-5:30 pm [Virtual] BOOK CLUB (Ages 6-9 *All ages are welcome*) Thursday 4-5:30 pm [In-Person]

Total Fees for Child 2 (For subsidy input "subsidy")

Home Address

City

Postal Code

Parent/Guardian Name

Parent/Guardian Email Address

Parent/Guardian Phone

Emergency Contact Name (Not the same as above)

Emergency Contact Phone

There will be occasions where pictures/video will be taken of participants for public relation purposes; Girls Inc Social Media, Newsletters, our website. There will be occasions where pictures/video will be taken of participants for public relation purposes; Girls Inc Social Media, Newsletters, our website. I give permission I DO NOT give permission

By completing this form: I give permission for the participant(s) to participate in Girls Inc. of York Region's virtual programming via the ZOOM platform and/or in-person programming. I agree that the participant(s) will join the zoom meetings on time in order to take advantage of the session information. I have provided Girls Inc of York Region with necessary medical information and may be reached at the phone number I provided. I acknowledge and accept the risk for any accidents or injuries arising by reason of participation in the program by the registered “participant(s)”. By completing this form: I give permission for the participant(s) to participate in Girls Inc. of York Region's virtual programming via the ZOOM platform and/or in-person programming. I agree that the participant(s) will join the zoom meetings on time in order to take advantage of the session information. I have provided Girls Inc of York Region with necessary medical information and may be reached at the phone number I provided. I acknowledge and accept the risk for any accidents or injuries arising by reason of participation in the program by the registered “participant(s)”. I agree

Parent/Guardian Signature (please type)

Date

Total Program Fees $$ (For subsidy input "Subsidy")

Payment Information Payment Information E-Transfer - [email barb@girlsincyork.org with "(Child Name), Spring ASP" in the message section] Credit Card Cash/Debit (In-Person at package pick-up) Subsidy

Name on Credit Card

Credit Card Number

Credit Card Expiry Date (mm/yy)

Package Pick-Up/Delivery (If choosing delivery or mail, you will receive a call to verify payment amount) Package Pick-Up/Delivery (If choosing delivery or mail, you will receive a call to verify payment amount) Delivery (minimum $10 fee depending on area) Pick-up (Girls Inc. of York Region Office) Mail (service charges may apply)