Membership Membership $50 Per Girl $80 Per Family Already a Member No Membership Subsidy

Child First Name

Last Name

Date Of Birth (MM/DD/YYYY)

Home Address

City

Postal Code

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. Zoom Programs ($20 for Members. $50 for Non-Members) Girls Inc. Zoom Programs ($20 for Members. $50 for Non-Members) Girls CLUB (Ages 6-8) Monday 4-5:30 pm Girls SQUAD (Age 9-12) Tuesday 4-5:30 pm Girls GROUP (Age 12-14) Wednesday 4-5:30 pm BOOK CLUB (Ages 7-10 ***grades 3-5 reading level) Wednesday 6-7 pm

Girl Boss Chess Zoom Programs ($60 Members. $100 Non-members. Subsidy NOT available) Girl Boss Chess Zoom Programs ($60 Members. $100 Non-members. Subsidy NOT available) Girl Boss Chess: Level 1 (Ages 6-8) Thursday 4-5 pm Girl Boss Chess: Level 1 (9-11) Thursday 4-5 pm Girl Boss Chess: Level 2 (All ages) Thursday 5:30 - 6:30 pm

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

Child#2 First Name

Child #2 Last Name

Date Of Birth

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. Zoom Programs ($20 for Members. $50 for Non-members) Girls Inc. Zoom Programs ($20 for Members. $50 for Non-members) Girls CLUB (Ages 6-8) Monday 4-5:30 pm. $20 for members. $50 non-members. Girls SQUAD (Age 9-12) Girls GROUP (Age 12-14) BOOK CLUB (Ages 7-10) ***grades 3-5 reading level

Girl Boss Chess Zoom Programs ($60 for Members. $100 for Non-Members. Subsidy NOT available) Girl Boss Chess Zoom Programs ($60 for Members. $100 for Non-Members. Subsidy NOT available) Girl Boss Chess: Level 1 (Ages 6-8) Girl Boss Chess: Level 1 (9-11) Girl Boss Chess: Level 2 (All ages)

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

Parent/Guardian Name

Parent/Guardian Email Address

Parent/Guardian Phone

Emergency Contact Name

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. 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. 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), Virtual ASP" in the message section of e-transfer. Credit Card Cash/Debit (In-person at package pick-up) Subsidy

Name on Credit Card

Credit Card Number

Credit Card Expiry Date (mm/yy)