Teen Girls Group

PLI Teen Girls Group
Child's Name

First NameLast Name
Did your child attend the Teen Girls Group this year?
Child's Birthday

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Does your child have any allergies? Please write below.
Child's Grade
School Name
Child's Phone Number (if older than 12 years old and has phone)
Please enter a valid phone number.Format: (000) 000-0000.
Do we have permission to communicate with your child using the above phone number?
Mother's Name

First NameLast Name
Mother's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Father's Name

First NameLast Name
Father's Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Child's Age
Does your child have any allergies?
What is your child allergic to?
Does your child take any medications?
What medication does your child take?
Does your child have any behavioral issues we need to be aware of?
What do we need to know about your child's behavior?
When did your family arrive in the United States?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Where are you from?
What language do you speak at home?
Do we have permission to take pictures or video of your child for PLI media?
Can we give your child minor medical treatment if needed?
Does your child have permission to leave PLI to go home without supervision?
Who will pick up your child?

Other
I give my child permission to attend PLI's Teen Girls Group. I do not hold PLI responsible for any sickness or injuries that may happen to my child while there. I do not hold PLI responsible for my child once he or she leaves PLI property. I give PLI permission to seek medical care if my child should need it while attending this PLI program.
Should be Empty:

PLI Teen Girls Group