I, as parent/legal guardian of the child listed above, give my permission for her to attend the Girls Inc. of Wayne County Summer 2020 program during the hours of 8:30am-5:00pm Monday through Friday for 7 weeks beginning Monday, June 15 - Friday, July 31, 2020. Due to the COVID-19 pandemic and staffing ratio restrictions, we can no longer offer Early Bird arrival and hours of operation have changed. I understand activities will occur both at the Center located at 1407 S. 8th St. Richmond, IN, and offsite during select field trips. It is understood that Girls Inc. of Wayne County will not be held liable for any accident or injury in or outside of the Center. In case of a medical emergency, I give permission for treatment to be administered as needed, in the event that I cannot be contacted. I understand that I will be financially responsible for the cost of treatment. Additionally, I grant permission for photos and/or video taken during Girls Inc. activities to be used for publicity purposes; including the Girls Inc.’s Facebook page.
INFORMATION SHARING AUTHORIZATION: I authorize the collection of pertinent information regarding behavior, attitude and knowledge including confidential information as deemed relevant by Girls Inc. for programmatic purposes. I give my consent to share information. By signing this form, I authorize Girls Inc. of Wayne County to exchange confidential information and work together with partner agencies (including schools) for Girls Inc. members (i.e. grades, attendance). This information will be used for required grant reporting, program assessment, and development of educational profiles of Girls Inc. members. I understand that personal records are protected by various federal and state laws and cannot be disclosed without this document noting my written consent, unless otherwise authorized.
We ask that you complete the following questionnaire. This information helps allows us to receive funding to continue offering our programs. All information is confidential. Mark all that apply.
Program fees will range from $125-$500 based on household income. A $25 non-refundable deposit is required for registration. Select below the program fee for your household.
A $10 late fee will be charged for each 15 minutes after 5:30 pm beginning at 5:31 pm.
