Summer Registration

Step 1 of 8

Child's Name #4:*
First Last
Date of Birth:*
Age:*
School:*
Entering Grade:*
- Kindergarten
- 1st Grade
- 2nd Grade
- 3rd Grade
- 4th Grade
- 5th Grade
- 6th Grade
- 7th Grade
- 8th Grade
List all conditions including food/medical allergies/health needs & restrictions:

Parent/Guardian Authorization
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 2022 program during the hours of 7:45 am-6:00 pm Monday through Friday for 8 weeks beginning Monday, June 6 - Friday, July 29, 2022. 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.
Parent/Guardian Signature:*
Parent/Guardian Name:*
First Last
Date*
MM slash DD slash YYYY

Contact Information
Relationship to Girl:*
Name:*
First Last
Address:
Street Address Address Line 2 City State ZIP Code
Home Phone:
Cell Phone:*
Place of Employment:
Work Phone:
Email:
Relationship to Girl:
Name:
First Last
Address:
Street Address Address Line 2 City State ZIP Code
Home Phone:
Cell Phone:
Place of Employment:
Work Phone:
Email:
Emergency Contact Information
Emergency Contact #1:*
First Last
Relationship to Girl:*
Phone:*
Emergency Contact #2:
First Last
Relationship to Girl:
Phone:
Emergency Contact #3:
First Last
Relationship to Girl:
Phone:

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

© 2022 Girls Inc. Wayne County.
1407 S. 8th St., Richmond, IN 47374 | 765.962.2362
INSPIRING GIRLS TO BE STRONG, SMART, & BOLD

Step 1 of 8

Parent/Guardian Authorization

Contact Information

Emergency Contact Information

Summer Registration

Registration Fees

Testimonials

Contact Us or Send a Testimonial

Thank You to Our Sustaining Champions

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