Child First Name

Last Name

Date Of Birth

School

Grade

Home Address

City

Postal Code

Has your child/youth attended programs before? Has your child/youth attended programs before? New Member Returning Member

Zoom Programs Zoom Programs Girls CLUB (Age 5-8) Girls SQUAD (Age 9-12) Girls GROUP (Age 13-16) LIT Program (Age 14-18)

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.:

Parent/Guardian Name

Parent/Guardian Phone

Parent/Guardian Email Address

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: 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)”.

Parent/Guardian Signature (please type)

Date