Girl Link Up Summer Camp | Registration Form

Girls Link Up - Summer Camp

June 5- June 30, 2023
THIS FORM WILL TAKE 15-20 minutes to complete and will require you to complete it at one time.

Registration Details:
- Registration period: Wednesday, March 1, 2023 to Monday, May 15, 2023.
- Please register using this form below.
- Payment method: cash or online payments
- Scholarships: To be considered for a camp scholarship, participants must meet the following requirements:
  - ___Youth applicant is between the age of 5 and 17 years old; OR
  - ____Youth applicant is 18 years old and currently enrolled in school (high school, GED program or equivalent, or post secondary institution) and will be enrolled in AND attend school during the upcoming academic year (Verification of school enrollment includes a letter from the school on official school letterhead):
  - OR ____Youth applicant is 18 - 19 years old and has a dependent child AND is the custodial parent
  - Receives one of the following benefits
    
    Temporary Assistance for Needy Families (TANF)
    
    Supplemental Nutrition Assistance Program (SNAP) (also known as Food Stamps)
    
    Medicaid or Social Security Income (SSI)
    
    Reduced or free lunch program at school – Note: This eligibility is only for single youth eligibility.
    This is not applicable if the entire school population is awarded free lunch in universal eligibility.
    
    Peachcare for Kids
    Scholarship applications will require an additional income verification form. Please be prepared to upload documents during this application.
Fees:
- Camp Registration Deposit: $50 (includes 5 camp uniform shirts)
- Weekly Camp Fees: $100 per week; $25 per week for scholarship recipients.
- Before Camp Care: $10.00/week
- After Camp Care: $10.00/week
Campers are provided with lunch and snacks throughout the day.

Contact:

For more information, please contact Raioni Madison at raioni@3dgirlsinc.org.
Camper's Name*

First NameLast Name
Sex - How does your child identify?*

MaleFemaleNon-binary
Current School Grade*
We only accept girls rising 3rd - 8th grade.
Current School *
Date of Birth*

MonthDayYear
Age:*
Medical Insurance Provider *
Medical Insurance Number*
Primary Care Doctor*
Allergies or Other Medical Conditions:*
Dietary Restrictions:*
Does your child show any signs of learning challenges? *
Does your child have an IEP that we should be aware of?*

YesNo
Does your child have any current behavioral health issues that our team should be aware of? (ex: stress, anxiety, depression, emotional outburst) *
Do you have any concerns about your child's learning capabilities? *
Are you interested in BEFORE camp care (7am - 8am)?*

Yes, I am interested.Before Camp Care not required
Are you interested in AFTER camp care (4pm – 6pm)?*

Yes, I am interested.After Camp Care not required

The summer camp provides two pathways for enrichment during the afternoons. The S.T.E.A.M. Pathway provides girls with a variety of hands-on and engaging activities. The Entrepreneurship Pathway provides support for girls with a desire to start a business. On Friday, June 30, 2023, we will host a participant showcase and pitch competition for girls on the entrepreneurship for girls to win prizes to support their venture. *

	1st Choice	2nd Choice
Entrepreneurship
S.T.E.A.M. Pathway

T-shirt Size (ADULT SIZE)*

SmallMediumLargeX-LargeXXL

PARENT/GUARDIAN INFORMATION
Parent/Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityProvince

Postal CodeCountry
Home Phone Number

Area CodePhone Number
Business Phone Number

Area CodePhone Number
Cell Phone Number*

Area CodePhone Number
E-mail*
Do you have legal custody of the child who is being registered?*

YesNo
Emergency Contact + Authorize Pick Up

In the case that we are unable to reach you in an emergency, please provide the name and number of someone we can contact (other than the parent above). Please identify authorized individuals who can pick up your child from camp.
Emergency Contact Name*

First NameLast Name
Emergency Contact Number*

Area CodePhone Number
Authorized Pick Up Contact #1*

First NameLast Name
Authorize Pick Up Contact #1*

Area CodePhone Number
Authorized Pick Up Contact #2*

First NameLast Name
Authorize Pick Up Contact #2*

Area CodePhone Number
Authorized Pick Up Contact #3*

First NameLast Name
Authorize Pick Up Contact #3*

Area CodePhone Number
Payment

Weekly camp fees are due the Friday before the following camp week. Camp Fees are due by 4pm on the following days: June 1, June 9, June 16, and June 23. Camp fees are $100 per week; Scholarship Camp Fees are $25 per week.
How will you be paying for the camp fee each week?*

In person - Cash/Money OrderOnline (Debit or Credit Cards)
Are you interested in applying for a scholarship for camp*

YesNo

Scholarship Eligibility Form
A. Is the youth applicant a U.S. citizen or qualified alien?

YesNo
B. Is the youth applicant a Georgia resident?

YesNo
Income Verification:

Income verification must be obtained and a copy must be attached to the youth’s income eligibility form. Examples of earned income verification are:

● Pay stubs or receipts for the most recent four weeks of earnings;

● W-2 Forms;

● Employer’s issued, signed and dated documentation;

● Personal income ledger or tablet (e.g. self-employed)

● Quarterly income tax returns;

● Annual income tax returns when presented in January – March quarter; Letter/statement from employer;

● Documentation from other DFCS staff such as the eligibility CM; and/or Form 809 or itemized statement completed by the employer.
Please upload your income verification below.

Browse Files

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Photographic & Media Consent
You are being asked to give consent for the collection and use of your child’s personal images by photography or video recording.

If you give consent, you are acknowledging that these images may be used on the 3D Girls, Inc. website, YouTube channel, newsletters, and publications as well as distributed to members or used for 3D Girls, Inc. promotion in the future.

No personal information, such as names, will be used in any publications unless expressed consent is given.
*

I HEREBY GIVE consent to the collection and use of my child’s personal images by photography or video recording.I DO NOT give consent for 3D Girls, Inc. to collect and use my child’s personal images by photography or video recording.

"Black Girl Dream Conference" - Field Trip

Memphis, TN - June 9 - 10th - INTEREST FORM
We will be going on an overnight trip to The Black Girl Dream Confernce Friday, June 9th-10th, 2023 .

If you permit your child to participate in this field trip, you are agreeing to indemnify and hold blameless 3D Girls, Inc. and its volunteers and staff from and against any loss, damage, or injury suffered by the participant as a result of being part of the activities of the field trip as well as of any medical treatment authorized by the supervising individuals representing the organization. This consent and authorization is effective only when participation in or traveling to and from Memphis, TN.

Trip Details:
- Destination: Memphis, TN - Black Girl Dream Conference hosted by The Southern Black Girls & Women's Consortium
- Date: Friday, June 9th - 10th 2023
- Transportation: Coach Bus
More details about the trip location, hotel, and activities will be published and shared with interested families mid-May 2023.

This is not a permission slip. This is an interest form.
*

I AM interested in my child participating in the overnight trip to Memphis, TN for The Black Girl Dream Conference.I AM NOT interested in my child participating in the overnight trip to Memphis, TN for The Black Girl Dream Conference.

Release Statement
I hereby consent to the participation of my child in all of 3D Girls, Inc. Girls Link Up supervised activities including Bible studies, indoor and outdoor recreational games, crafts, field trips, and lunch and snack times.

I, the Parent or Guardian named below, authorize the Director or one of 3D Girls, Inc. Girls Link Up personnel to sign consent for medical treatment and to authorize any physician or hospital to provide medical assessment, treatment, or procedures for the participant named above.

I, named below, undertake and agree to indemnify and hold blameless 3D Girls, Inc., its Personnel, its Leaders, and Board from and against any loss, damage or injury suffered by the participant as a result of being part of the activities of Girls Link Up, as well as of any medical treatment authorized by the supervising individuals representing 3D Girls, Inc. This consent and authorization is effective only when participating in or traveling to events of 3D Girls, Inc. Girls Link Up Summer Camp.

I have read, understood and agree with above.
Name*
Signature*

Registration Fee (Include 5 Camp T-Shirts)

Summer Camp Registration $50.00

June 5 - 30th, 2023

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Total $0.00

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Girls Link Up - Summer Camp

PARENT/GUARDIAN INFORMATION

Emergency Contact + Authorize Pick Up

Payment

Scholarship Eligibility Form

Photographic & Media Consent

"Black Girl Dream Conference" - Field Trip

Release Statement