One Time Registration Fee: $15.00. *Additional forms may be required for specific programs* Please Indicate * New Renewal Drop-In Swim Lessons Basketball Dear World Leadership Academy STEM Seven Hills Member Information Name Date of Birth Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year19241925192619271928192919301931193219331934193519361937193819391940194119421943194419451946194719481949195019511952195319541955195619571958195919601961196219631964196519661967196819691970197119721973197419751976197719781979198019811982198319841985198619871988198919901991199219931994199519961997199819992000200120022003200420052006200720082009201020112012201320142015201620172018201920202021202220232024 Current Age Address City Zip School Grade Child currently lives with Relationship with the child Parent/Guardian InformationPrimary Parent/Guardian Name Phone #1 Phone #2 E-Mail Address Please Indicate Custodial Parent Non-Custodial Parent Guardian Marital Status Married Partnered Divorced Single Widowed Separated Primary Language spoken at home Secondary Language (if applicable) Employer Work Phone Secondary Parent/Guardian Name Phone #1 Phone #2 E-Mail Address Please Indicate Custodial Parent Non-Custodial Parent Guardian Marital Status Married Partnered Divorced Single Widowed Separated Primary Language spoken at home Secondary Language (if applicable) Emergency Contacts & Authorized Pick-Ups(In Case of Emergency, Parents/Guardians are always contacted first) First Emergency Contact Name Phone #1 Phone #2 Authorized Pick-Up Yes No Second Emergency Contact Name Phone #1 Phone #2 Authorized Pick-Up Yes No Third Emergency Contact Name Phone #1 Phone #2 Authorized Pick-Up Yes No The following information issued for grant purposes only.It will not be shared. Income Level Under $17,000 $17,000 to $20,999 $21,000 to $24,999 $25,000 to $49,999 $50,000 and above Number of People in Household 1 2 3 4 5 6 and up Ethnic Background Asian/Pacific American Black/African American Latino/Hispanic American Indian/Native American White/European American Multiracial/Multiple Heritage Other Medical Permission FormBy electronically signing this registration form, I give permission for my child to receive emergency treatment and to be hospitalized at my expense, if necessary. I understand that every effort will be made to contact me before taking action. I also agree to update Girls Inc. of Worcester if there are any changes in the following information. Doctor's Name Telephone Preferred Hospital Medical Insurance Carrier Policy Number Please Briefly List Any Allergies, Medications, and/or Health Concerns Girls Incorporated Activity Permission Parent/Guardian Initials * I give permission for my child to participate in Girls Incorporated Signature programs and to be transported by Girls Incorporated staff to and from these activities, field trips, and school centers. I understand that my medical coverage is the primary insurer for my child and will not hold Girls Inc. responsible in case of an accident. Parent/Guardian Initials * 2. I give permission for images in print and electronic form and videos taken of my child during programs to be used for public relations purposes in newsletters, brochures, annual reports and for publicity on our website, radio, television, and newspapers. Parent/Guardian Initials * 3. I am aware there is a late fee of $15.00 for each 15 minutes that I am late to pick up my child. Parent/Guardian Electronic Signature * Date * Month MonthJanFebMarAprMayJunJulAugSepOctNovDec Day Day12345678910111213141516171819202122232425262728293031 Year Year202420252026202720282029 How did you first hear of Girls Incorporated? Newspaper/Radio/Television Internet Family/Friend Other
