Registration Form 2013-2014

One Time Registration Fee: $15.00. *Additional forms may be required for specific programs*

Member Information

Name

Date of Birth

Month

Day

Year

Current Age

Address

City

Zip

School

Grade

Child currently lives with

Relationship with the child

Medical Permission Form

By 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

Day

Year

How did you first hear of Girls Incorporated?

Newspaper/Radio/Television

Internet

Family/Friend

Other

Go Local Worcester Article

Release Date:

Thu, 08/15/2013

Famed Escape Artist to Perform for Girls Inc. of Worcester

Thursday, August 15, 2013

GoLocalWorcester Lifestyle Team

Alexanderia the Great should an inspiration for escape artists and young women everywhere.

Alexanderia the Great Appearance

August 16, 2013 - 9:00am to 11:30am

Girls Inc. of Worcester

125 Providence Street

Worcester, MA 01604

See map: Google Maps

Online Internship Application

All potential interns are required to send in a cover letter, complete an application, agree to release information leading to a criminal history and reference check, and attend an interview at our 125 Providence Street location. Each accepted intern will be provided with a training session/s, project description, and all resources needed prior to beginning their assignment. Girls Inc. of Worcester reserves the right to decline a internship applicant for any reason, at any time.

Personal Information

Please Upload Cover Letter *

Files must be less than 800 bytes.
Allowed file types: txt rtf html odf pdf doc docx ppt pptx xls xlsx xml.

Is this internship for academic credit? *

Yes

No

First Name *

Last Name *

Middle Initial

Maiden Name (if applicable)

Date of Birth *

Month

Day

Year

Ethnicity

Full Address

City, State

Zip Code

Home Phone

Work Phone

Cell Phone

Email Address *

Current Place of Work

Current Job Position

Education and Training

Please include information from college, and/or other educational training.

First Institution

Institution Name *

Area/Major *

Years Studied *

Second Institution

Institution Name

Area/Major

Years Studied

Third Institution

Institution Name

Area/Major

Years Studied

Previous Volunteer Experience

Please include information from your most current volunteer experiences.

First Institution

Institution Name *

Position Held *

Dates *

Second Institution

Institution Name

Position Held

Dates

Third Institution

Institution Name

Position Held

Dates

References

List two persons unrelated to you who can speak about your volunteer or work experience.

First Reference

Name *

Relationship *

Phone

Email Address

Second Reference

Name *

Relationship *

Phone

Email Address

Permission to Complete Background Check

I give permission for Girls Incorporated of Worcester to perform a check of my background, including: criminal record, past employment and volunteer history, educational and professional status and personal references. I understand that I do not have to agree to this background check, but that refusal to do so may exclude me from acceptance into the Girls Incorporated of Worcester internship program. I understand that information collected during this background check will be limited to that which is appropriate to determining my suitability for particular types of internship projects and that all such information collected during the check will be kept confidential. I understand that Girls Incorporated of Worcester provides equal internship opportunities to all qualified applicants without regard to race, religion, color, sex, gender, age, disability, marital status, sexual orientation, socioeconomic status, veteran status or national origin. I hereby also extend my permission to those individuals or organizations contacted for the purpose of this background check to give their full and honest evaluation of my suitability of the described internship project and such other information as they deem appropriate.

Applicant Electronic Signature *

Date *

Month

Day