I, as parent/legal guardian of the child(ren) listed above, give my permission for her(them) to attend the Girls Inc. of Wayne County Summer 2021 program during the hours of 8:00 am-5:30 pm Monday through Friday for 8 weeks beginning Monday, June 7 - Friday, July 30, 2021. An Early Bird (7:30 am) arrival is available. 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.

By signing this form, I authorize Girls Inc. of Wayne County to exchange confidential information and work together with partner agencies. This information will be used for required grant reporting to assess program progress. I understand that personal records are protected by various federal and state laws and cannot be disclosed without this, my written consent, unless otherwise authorized.

Photo release: I give my consent for photos/videos taken during Girls Inc. activities to be used for publicity purposes, including online and in print.

Liability Waver: I agree that Girls Inc. of Wayne County will not be responsible for any accident to my girl while at Girls Inc.or while she is engaged in any offsite activities. I acknowledge that I have received the Code of Conduct and agree to abide by the rules and regulations as explained in it.

Payment Policy: I have read and agree to the Membership Payment Policy.

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.

$75 per week fee/$50 per week sibling rate.

A $10 late fee will be charged for each 15 minutes after 5:30 pm beginning at 5:31 pm.

Summer Session dates, times, and locations have not been determined for Connersville, Fountain City, Hagerstow, and Union County. Once this information is available, you will be notified by a member of our staff.