Membership Form

Membership Registration
All information submitted will be kept confidential. It helps us in applying for grants and other funding available for non-profits. We appreciate you completing this as thoroughly as possible to help in that process.
Student Information
Student Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Birthdate*

MonthDayYear
Date
Age*
Grade *
School*
Best Contact Number*
Please enter a valid phone number.
Contact Number Belongs To*
Race / Ethnicity*
Social Security Number
Medical Information
Physician's Name
Physician's Phone Number
Please enter a valid phone number.
Preferred Hospital
Allergies
Insurance Carrier
Policy Number
Primary Guardian Information
Primary Guardian's Name*

First NameLast Name
Primary Guardian's Relationship*
Primary Guardian's Phone Number*
Please enter a valid phone number.
Primary Guardian's Email*
example@example.com
Primary Guardian's Race / Ethnicity
Primary Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Guardian's Employer
Primary Guardian's Employer Phone
Secondary Guardian Information
Secondary Guardian's Name

First NameLast Name
Secondary Guardian's Relationship
Secondary Guardian's Phone Number
Please enter a valid phone number.
Secondary Guardian's Email
example@example.com
Secondary Guardian's Race / Ethnicity
Secondary Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Guardian's Employer
Secondary Guardian's Employer Phone
Additional Emergency Contact

Other than guardian(s) listed above
Emergency Contact Name

First NameLast Name
Emergency Contact Phone Number
Please enter a valid phone number.
Emergency Contact Relationship
Household Information
Primary Language Spoken at Home*
Household Income*
Are parents separated?*
If yes, who does the child live with?
Releases & Waivers
Media Release*
Medical Waiver*
Program Release*
Transportation Release*
Parent/Guardian Signature*

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Date Signed*

MonthDayYear
Date
Membership Fees

Membership fees must be paid at the time of registration. Please inquire in our office if financial assistance or payment plans are necessary. Assistance provided in part by CDBG funds. If fees are not paid by due dates, legal action may be taken. Girls, Inc memberships are non-refundable.
Pay Now*
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Girls, Inc. One-Year Membership Fee
$30.00

Total

$0.00
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Membership Registration

Student Information

Medical Information

Primary Guardian Information

Secondary Guardian Information

Additional Emergency Contact

Household Information

Releases & Waivers

Membership Fees