Member Registration Form

Step 1 of 6 - Child

Child Information
Child's Name:*
First Last
Date of Birth:*
MM slash DD slash YYYY
Age:*
School:*
Grade this Fall:*

Primary Parent/Guardian Information
Name:*
First Last
Relationship:*
Address:*
Street Address Address Line 2 City State ZIP Code
Best Phone Number to Reach You:*
Phone Type:*
2nd Phone Number to Reach You:
Phone Type:
Email:*
Secondary Parent/Guardian Information
Name:
First Last
Relationship:
Address:
Street Address Address Line 2 City State ZIP Code
Best Phone Number to Reach You:
Phone Type:
2nd Phone Number to Reach You:
Phone Type:
Email:

Emergency Contact
If Primary and Secondary Contacts Cannot Be Reached
Name*
First Last
Relationship:*
Address:*
Street Address Address Line 2 City State ZIP Code
Best Phone Number to Reach Them:*
Phone Type:*
2nd Phone Number to Reach Them:*
Phone Type:*
Other Contacts Authorized to Pick Up Your Child
Name:
First Last
Phone:
Name:
First Last
Phone:
Name:
First Last
Phone:

Consent to Share Information
Please read the following statement and check the box to give your consent:*
- 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.
Please read the following statement and check the box to give your consent:*
- 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.
- I do not give my consent for photos/videos taken during Girls Inc. activities to be used for publicity purposes.
Please read the following statement and check the box to give your consent:*
- Libaility Waiver: I agree that Girls Inc. of Wayne County will not be responsible for any accident to my girl(s) 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.
Please read the following statement and check the box to give your consent:*
Click HERE to read our COVID-19 document.
- I acknowledge that I have read the COVID-19 document.
Signature:*
Please use your mouse, stylus, or finger to sign in the box above.

Registration Fee
Registration Fee:*
- Pay Monthly - $10 per month
- Pay In Full - $85 (if paid in full by Sept. 1st)
- Pay In Full - $100 (if paid after Sept. 1st)
First Month Program Fee Required to Register
Total
Payment Method:*
- I would like to pay the total due by credit card
- I would like to pay ONLY the first month's fee ($10) by credit card to hold my child's spot
- I would like someone to contact me about payment options
Payment Amount:*

If you are paying the $10 monthly fee to hold a spot for your child, it will be deducted from your amount due.
Credit Card
Card Details
Cardholder Name

Testimonials

I wasn't born in Richmond and I had a hard time making friends; Girls Inc. enable me to make friends. Girls Inc. has really helped my life and I really enjoyed going there for plenty of reasons. I feel bad because this is my last year and I wish I could continue to come or at least work there. Girls Inc. and their staff mean a lot to me.
JaMarie

Bold is my word because I do try my hardest, I am outgoing, I love kids and people in general, I get involved with new activities and complete my tasks. It takes being strong and smart to become a bold outspoken young woman and I plan on being the same bold (sort) of person for the rest of my life. Thanks to Girls Inc. I can be.
Naomi

My favorite thing about Girls Inc. was the way (my girls) talked about it at the end of the day, full of stories about what they learned and did.
Parent