Girls Group Registration

Girls Group Registration
Name

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Date of Birth

Month Day Year
Date
I can receive TEXT Messages

YES NO
T-Shirt Size
Parent / Legal Guardian

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
I can receive TEXT Messages

YES NO
Parent / Legal Guardian #2

First Name Last Name
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Work Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Emergency Contact

First Name Last Name
Relationship to Child(ren)
Phone Number
Please enter a valid phone number.
Pick up / Dismissal

*If we aren't there exactly at 5:00PM please be patient we are on our way!*
My Child has their own ride to and from group My Child can walk to and from group My Child will need a ride to and from group
*Group typically runs from 5:00PM - 7:00PM but often runs a little after 7:00PM because we want to make sure the girls are being heard. *

Emergency Medical Release
Emergency Medical Release (*Must be initialed for your child to participate) My indicating yes indicates that in the event of an emergency and in the event that: (1) a parent/ legal guardian or the authorized/ designated individual(s) cannot be reached; or (2) immediate medical attention is necessary, I consent to have Girls Group staff/ leaders/ volunteers act in my behalf and hereby grant my permission for emergency treatment to be administered until a parent/ legal guardian or the authorized/ designated individual(s) identified can be reached. I am consenting to any X-ray examinations, anesthetic, medical, surgical, or dental diagnosis or treatment and hospital care, to be rendered to the minor under general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to his/her authorization. I agree not to hold Girls Group or any staff/ leaders/ volunteers liable for any decisions, for any medical treatment made under this authorization or for any accident or loss to the student, however caused.
Liability Release
Liability Release (*Must indicate yes for your child to attend) In addition, I do hereby release, forever discharge and agree to hold harmless the Girls Group Leaders thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in any trip or activity.
Permission to Transport
Permission to Transport I give Girls Group permission to transport my son/daughter to and from Girls Group programs and related events
Promotional Release
I release Girls Group to use photos, video, and audio of student in promotional materials that support the Girls Group and its programs. I release Girls Group from any liability connected with the use of my picture or voice recording as a part of any promotional recruitment or fundraising programs
Consent to Discuss
Consent to discuss (*Must be initialized for your child to attend) At Girls Group we will discuss current event topics and touch on possible sensitive subjects during group. Our leaders are dedicated to talking through hard topics in a healthy way and will remain committed to that. I understand that my daughter might be apart of a conversation with a topic that might be being introduced to her and I understand and agree that the leaders are acting in the best interest of the child and is not liable for what they might learn through their peer lead discussions.

My acknowledgement in each category and my signature below indicates that I have read and do agree to the conditions listed above and that I have given accurate and necessary information regarding the above-named child.
Parent/Legal Guardian

First Name Last Name
Signature

Clear
Date

Month Day Year
Date
Should be Empty:

Girls Group Registration

Pick up / Dismissal