Marietta Afterschool Application

MARIETTA
AFTERSCHOOL APPLICATION

General Information
Address:
Girls Inc. of Greater Atlanta 461 Manget St Marietta, GA 30060

Telephone:
770-422-0999

Office Hours:
9:00am to 5:00pm

Afterschool Hours:
2:30pm to 6:00pm

August 5, 2024 – May 16, 2025
*Girls Inc. will be closed during specific holidays.
Please contact your site staff for details.

Please review pages 1 - 3 and retain for your records.
Pages 4-25 must be completed and returned with all required documentation.
Registration Requirements

All the following items are required for your registration to be complete. We thank you in advance for completing and submitting the additional required documentation. It is required due to our government funding, which enables us to keep your costs low.
Complete Application Packet for each participant:

$50 Processing Fee$45 Tuition Fee per weekReport Card (most recent)Proof of Residency for primary Parent/Guardian (ex: Photo ID or check stub with current address, utility bill or lease which lists address)Copies of photo IDs for all household members over the age of 18Copies of Social Security card for all household members over the age of 6Proof of all household income for persons over the age of 18 (ex: 2 months of current and consecutive check stubs if paid weekly = 8 check stubs, paid bi-monthly = 6 check stubs, semi=monthly = 4 check stubs), monthly = 2 check stubs), or signed letter from employer on company letterhead, TANF records, food stamps, free and reduced lunch verification, alimony/child support, unemployment & disability income, armed forces income, pension/retirement income)If there is no-income in the household or you are self-employed you must complete a notarized Self- Certification of No Income or Self-Certification of Self Employment form. Forms are available at Girls Inc.
Registration materials can be dropped off in the locked mailbox in front of Girls Inc., by fax to 770-499-2386, or by email to Vanessa Mackey at vmackey@girlsincatl.org or Cathy Anderson at canderson@girlsincatl.org.

Any questions regarding the application or documentation needed can be directed to either Vanessa Mackey or Cathy Anderson at the above email address.

Your registration is not complete, and your spot will not be held until we have received your completed application packet, tuition fees, and ALL supporting documentation. You may pay your tuition fees through PayPal on our website at www.girlsincatl.org or Cash App ($girlsincatl). Please note that when you register you are committing to pay for the entire session. Girls Inc. does have daily rates.

Programming Schedule

At Girls Inc. your girl will participate in a wide variety of activities daily and week. While schedules will vary, most days include three activities: informal time, program time, and homework / tutoring time. The typical daily schedule is below.

Daily Schedule

2:30-3:00 – Cobb Girls Arrive at Center
3:30-4:30 – Marietta Girls Arrive at Center
3:00-4:00 – Snack/Informal Time
4:00-5:00 – Girls Inc. Programming
5:00-6:00 – Homework/Tutoring
Payment Policies

Tuition Rates by Income:
$0 - $20,000 = $38 weekly
$20,001 - $30,000 = $40 weekly
$30,001 - $40,000 = $42 weekly
$40,001 - plus = $45 weekly

Tuition Responsibilities: If a participant does not attend due to illness, transportation issues, or other unforeseen circumstances, there will be no tuition refunds. In addition, refunds will also not be issued if the participant is dismissed due to behavior. No participants will not be allowed to attend if registration is not completed in full.

Payment Option: This year all parents/guardians are required to link a card or account number for automatic payments. All parents/guardians will receive a link to our Brightwheel platform for payment options.

*Please make sure you include your child’s name when making payments.

Late Pick-up: Girls Inc. Afterschool Program closes at 6:00pm. Late pickup fees begin to accrue at 6:05pm, after which you will be assessed a fee of $1.00 for every minute you are late. Late pickup fees are due within one week of when they are incurred. In the event of consistent late pick-ups, or extremely pick-ups, Girls Inc. reserves the right to increase fees or even dismiss participants from the program.
Scholarship

As seen under the Payment Policies, scholarships will be rewarded by income at a weekly rate. Please see table below. Can you please put the weekly rates there again.

Below are the federal low-income guidelines that are utilized by our funders to determine funding eligibility. This is for your information only and does not affect your participation in this program.
Member Information Form
Participant Information
New MemberReturning Member
Name

Legal First NameLegal Middle NameLegal Last Name
Date of Birth

MonthDayYear
Date
Age
Gender (Female, Male or Other)
School Attending
School District
Grade (upcoming school term)
Address

Home Address/P.O. Box/Apt #

Street Address Line 2

CityState

Zip Code
Is the student an ESOL* student:

YesNo
What language(s) is spoken in your home?

EnglishSpanishOther
Ethnicity:

Black, Non-HispanicWhite, Non-HispanicHispanic/LatinoAsianHawaiian Native/Pacific IslanderAlaska Native/American IndianOther
Is the student a special needs student?

YesNo
If yes, please specify the child’s special need(s):
Does the student require special accommodations?
Does your child have a Individualized Family Service Plan (IFSP) or Individualized Education Plan (IEP).

YesNo
Do we have permission to share information with the your child’s teacher or school representative?

YesNo
Please select t-shirt size:

YSMYMYLASAMALAXLAXXL
Participant lives with:

One ParentGroup HomeBoth ParentsGrandparentsGuardian/CaregiverFoster HomeOther

List of family members in the household

	Name	Age

Do you receive free/reduced lunch?

YesNo
Are you applying for a scholarship?

YesNo
Is someone in the household currently receiving: (check all that apply)

Food StampsTANFMedicaidSSDISSIFree/Reduced School Lunch
How many people are in the household?
Please provide your income level:

$0 – $10,000$30,001 – $50,000$10,001 – $20,000Over $50,001$20,001 – $30,000
How did you hear about Girls Inc.?
I (print name)
certify that all the information given in this form are correct and true to the best
of my knowledge. I understand that providing false information may result in my child not being able to participate in the afterschool care program.
Parent or Guardian Signature

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Date
Medical & Behavioral Information

Please list any medical information we should be aware of including any allergies, medications,
diagnoses or other concerns. Please include any way these conditions or behaviors may need addressed or accommodated. For example, if your child has been diagnosed with ADHD and/or Autism, please describe behaviors we should expect to see or if there are behavior modification techniques (incentives or disciplines) used at home or at school. This will help us work with you as a team to help your child succeed and ensure that your child receives consistent messages to avoid confusion. Please attach additional information or discuss this with us as necessary.
Contact Information Form
Primary Parent or Guardian Contact
Name

First NameLast Name
Relationship to participant:
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Best phone # to reach you
Phone Type:
2nd phone # to reach you
Phone Type:
Secondary Parent or Guardian Contact
Name

First NameLast Name
Relationship to participant:
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Best phone # to reach you
Phone Type:
2nd phone # to reach you
Phone Type:
Other contacts authorized to pick up child.
Name
Phone
Relationship
Name
Phone
Relationship
I have provided Girls Incorporated of Greater Atlanta with all necessary medical information and can be reached at the numbers listed. I acknowledge and accept the risk for any accidents or injuries arising by reason of participation in the program, by myself or the person who is shown as the "participant." I agree to indemnify and hold harmless participants Incorporated of Greater Atlanta officials, staff, officers, volunteers, and community partners harmless from any accidental injury or loss of property that may occur to the participant or myself while participating in any of participants Incorporated of Greater Atlanta’s programs.
Parent/Guardian Signature:

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Date
Acknowledgement of Girls Inc. Policies
I,
parent/guardian of
have read and understand the payment policies that have been set forth by Girls Inc. of Greater Atlanta and included in pages 2-11 of this registration packet. I acknowledge that it is my responsibility to adhere to all these policies and make all required payments by the stated deadlines, including tuition payments for the month your child registers for regardless of attendance.
Parent/Guardian Signature:

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Date
Bright From The Start Notice of Exemption

I acknowledge that I have been informed that this program is not licensed. I also understand this program is not required to be licensed by Georgia Department of Early Care and Learning and this program is exempt from state licensure requirements.
Parent/Guardian Signature:

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Date
I have reviewed and explained eligibility requirements and responsibilities of the person who signed this form.
Girls Inc. Staff’s Signature:

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Girls Inc. Staff’s Signature:

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Field Trips/Special Events Permission Form
I
, hereby give permission for my child to attend Girls Incorporated of Greater Atlanta under the supervision of Girls Inc. staff and participate in field trips, onsite/offsite special events. I understand that activities may have certain unavoidable risk and agree to indemnify and hold harmless Girls Incorporated of Greater Atlanta, staff, volunteers, officers, and partners in case of an accident or injury. If I cannot be reached, I give permission for Girls Inc. staff to contact and discuss the situation with the emergency contacts listed below.
Participant's Name
Parent/Guardian's Name
Relationship to Participant
Parent/Guardian Signature:

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Date
Contact Number 1
Contact Number 2
Media Consent and Release Form
I,
parent/guardian of
give permission for my child to be photographed, videotaped, and/or interviewed by Girls Inc. of Greater Atlanta or our partners for program documentation, marketing, and promotional materials.
Signature

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Emergency Treatment Permission
Please provide the best way to reach you, as well as any relevant information that staff may need to know in an emergency.
I
give permission for my daughter child to receive emergency medical treatment and hospitalization, if necessary and understand payment will be my responsibility. If I cannot be reached, I give permission for Girls Inc. staff to contact and discuss the situation with the emergency contact listed below.
Participant's Name:
Parent/Guardian's Name:
Relationship to Participant:
Parent/Guardian Signature:

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Date
Contact Number 1
Contact Number 2
Additional Emergency Contact
Contact Name:
Relationship to Participant
Contact Number 1
Contact Number 2
Additional Emergency Contact
Contact Name:
Relationship to Participant
Contact Number 1
Contact Number 2
Insured Name:
Insured Name:
Insured Birthdate

MonthDayYear
Date
Medical Insurance
Group Number
Policy Number
Other relevant emergency information (medicine allergies, specific instructions, etc.)
Girls Inc. Medication Permission
For safety reasons and legal purposes, staff is not allowed to dispense prescription or non-prescription medication. Whenever possible, please administer necessary medications before or after coming to Girls Inc. However, if your child has prescribed medication that needs to be administered during the time, your child is present at the center, your child will be allowed to administer her own medications when necessary.

Administration of medication includes but does not limit to taking their own inhaler and/or opening their dispenser and taking their own capsules or pills. All medication must be in its original container and should state your child’s name and instructions.

Medications that do not follow original descriptions or are found inconsistent with instructions from their original dispenser (such as different color, different marks, different shapes) will not be accepted.
Child’s Name
Parent/Guardian’s Name
MEDICAL INFORMATION
Does the child have any allergies?

YesNo
If yes, please list them;
Does the child have any other medical conditions (disabilities, infections, viruses, diseases, etc)?

YesNo
If yes, please list them;
Is the child currently taking any medications (prescribed and non-prescribed)?

YesNo
If yes, please list them;
Medication Name
Medication instructions and any other important information:
By signing this form, I certify that I agree with the Girls Inc. policies and procedures regarding medication. I also certify that the child mentioned above understands and is capable of administering her own medication(s) without any assistance from Girls Inc. faculty and staff.
Parent/Guardian Signature

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Social & Emotional Wellness Questionnaire
Girls Inc. of Greater Atlanta is committed to supporting the overall health of our participants and families that includes the well being of their emotional and mental health. Through this questionnaire, we are focused on developing programs that supports our participants at every level and stage of their adolescent development. Helping them to learn and implement healthy coping skills, impulse control, anger management and build self-esteem.

Please know that all information that is provided is subject to strict HIAA confidentiality rules and guidelines. Only authorized personnel within Girls Inc. Greater Atlanta will have access to this information, unless written consent is given by a parent/legal guardian.
Student’s Name
Age
Grade
1. Has your child experienced bullying in the last six month?

YesNo
Explain
2. Has your child experienced any anxiety and/or depression in the last six month?

YesNo
Explain
3. Has your child experienced a traumatic situation in the last six months?

YesNo
Yes (If so, please explain)
4. Has your child expressed thoughts of harming themself or anyone else in the last six months?

YesNo
Explain
5. Has your child received therapy or any other mental health services in the last six months?

YesNo
Yes, (if yes, is your child still receiving therapeutic support)
6. Has your child received a mental health diagnosis in the last 2 years?

YesNo
Yes, (if so, please explain)
7. Has your child been hospitalized in the last six months?

YesNo
Explain
8. Has your child been prescribed medication to help address their emotional, mental and/or behavioral health needs in the last six months?

Yes (if yes are they taking are they taking the medication asNo
instructed
9. Is there anything that you would like to share with us about your child’s emotional and/or mental health?
CDBG PROGRAM OFFICE
CONSENT AND AUTHORIZATION TO DISCLSE AND

USE CONFIDENTIAL INFORMATION
Subreceipient Name
Subreceipient Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Client(s) Name
Client(s) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
I/We the undersigned Client or, in the case of a minor, the parent or guardian, hereby voluntarily consent and grant permission:
1. To the above-named person or entity to fully disclose, discuss with and release to a representative of Cobb County's CDBG Program Office any and all private, confidential, and other information and provide all documents necessary and useful in completing my/our application for federally funded services or for providing said service through the following program: Community Development Block Grant, HOME Investment Partnership Program, Community Service Block Grant or the Emergency Solutions Program.
2. For the above named Subrecipient of grant funds to fully disclose, discuss with and release to the above named person or entity any and all information and documents necessary and useful to complete all applications or for providing said services.
I/We understand that the above named Subrecipient, representatives of the Cobb County CDBG Program Office, Cobb County Government, US. Department of Housing & Urban Development, U.S. Department Human Service, U.S Office of Inspector General, and any other related agency will treat this information in a confidential manner. However, I/we voluntarily consent and grant permission to the Subrecipient and its representatives to use and fully disclose, discuss, and release any information to persons who have a need to know such information for my application of eligibility/evaluation for the provision of services through the grant programs. Unless revoked in writing delivered to Subrecipient, this Consent and Authorization will expire on the date that the client is no longer involved or enrolled in the Program. No revocation shall affect any action that has been taken in reliance on this Consent and Authorization. The recipient can rely on the presentation of this Authorization as proof that it has not expired or been revoked.

I/We understand that in order to enroll in or receive services through the Program, I/We must sign this Consent and Authorization. I/We certify that prior to signing this Consent and Authorization, I/we read it and understand all items and terms herein and that this Consent and Authorization is signed and given freely, voluntarily, and knowingly. A copy or facsimile of this Consent and Authorization shall be as valid as the original. I/We have received a copy of this form.
Client, Parent, or Guardian Signature

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DFCS Eligibility Form Instructions
Please read instructions below before completing DFCS Eligibility Form

Instructions on completing the following sections:

Youth Information – This section must be completed in its entirety.

Section 1 – Select A, B, & C and check Youth applicant is between the age of 5 and 17 years old Section 2 – Only select ONE of the following that you qualify for (if you qualify for multiple benefits ONLY check one box The one that you select you will need to provide evidence that you are receiving these benefits. Acceptable documents that we can accept per benefit).

OR

TANF – Official documentation showing the family/youth is currently receiving benefits at the time of application/enrollment into the afterschool care program (Georgia Gateway documentation), Official Letter from the Georgia Division of Family and Children Services outlining the receipt of benefits

OR

SNAP – Official documentation showing the family/youth is currently receiving benefits at the time of application/enrollment into the afterschool care program (Georgia Gateway documentation), Official Letter from the Georgia Division of Family and Children Services outlining the receipt of benefits

OR

Medicaid - Official documentation showing the family/youth is currently receiving benefits at the time of application/enrollment into the afterschool care program (Georgia Gateway documentation), Official Letter from the Georgia Division of Family and Children Services outlining the receipt of benefits

OR

SSI - Official documentation showing the family/youth is currently receiving benefits at the time of application/enrollment into the afterschool care program (Georgia Gateway documentation), Official Letter from the Georgia Division of Family and Children Services outlining the receipt of benefits

OR

Free/Reduced Lunch – You can either provide us with a letter they sent you 2020/2021 or

call the appropriate Nutrition department depending on which school your daughter attends. This does not qualify you if the entire school receives it. You have to have documentation that states your child receives it in which you would have applied.

OR

Peachcare for Kids - Official documentation showing the family/youth is currently receiving benefits at the time of application/enrollment into the afterschool care program (Georgia Gateway documentation), Official Letter from the Georgia Division of Family and Children Services outlining the receipt of benefits

Section 3 – Complete only if you did not check any benefits in Section 2

Section 4 – Complete only if you did not check any benefits in Section 2 -
For income you will need to provide one of the following: one-month current pay stubs or letter from employer or personal income ledger if self- employed or unemployment insurance claim records or Social Security Benefits or Child Support

Section 5 - To be completed by all parents/guardians

Official Documentation can be found on Georgia Gateway website at Gateway.ga.gov/access
Name of Youth Participant (Last)
(First)
(MI)
Social Security Number
Gender:

MaleFemale
Date of Birth (mm/dd/yy)

MonthDayYear
Date
Is the youth named above in Foster Care within the state of Georgia

YesNo
Note: If the youth is in Foster Care but not in the care of Georgia, please provide the state name
A. Is the youth applicant a U.S. citizen or qualified alien?

YesNo
B. Is the youth applicant a Georgia resident?

YesNo
C. Does the youth applicant fall into one (1) or more of the three categories below (Answer YES or NO and check all categories below that apply to the youth)?:

YesNo
Youth applicant is between the age of 5 and 17 years old; ORYouth applicant is 18 years old and currently enrolled in school (high school, GED program or equivalent, or postsecondary institution) and will be enrolled in AND attend school during the upcoming academic year (Verificationof school enrollment includes a letter from the school on official school letterhead): ORYouth applicant is 18 - 19 years old and has a dependent child AND is the custodial parent
A. Temporary Assistance for Needy Families (TANF)

YesNo
B. Supplemental Nutrition Assistance Program (SNAP) (also known as Food Stamps)

YesNo
C. Medicaid or Social Security Income (SSI)

YesNo
D. 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.

YesNo
E. Peachcare for Kids

YesNo
If the answer to at least one question in section 2 is YES, the youth is eligible to participate in the program and the parent/custodian/guardian may complete Section 5. Verification for receipt of services checked in Section 2 must be provided and a copy of the verification must be attached to this eligibility form. If the program does not receive verification of items checked in Section 2, the youth will not be able to participate in the program.

If the answer to ALL of the questions in Section 2 is NO, the parent/custodian/guardian MUST complete Section 3, Section 4 and Section 5 for eligibility determination. Verification for items listed in Section 3 and Section 4 must be provided and a copy of the verification must be attached to this eligibility form.
Page 2 of 3 – DFCS Out of School Services Eligibility Form
Family Unit Size*
Gross Household Yearly Income $
Gross Household Monthly Income $
Household Composition and Income

Gross Monthly Income is income before taxes and deductions.

	Name (First, Middle, and Last)	Relationship	Date of Birth (MM/DD/YY)	Income Source	Amount (Gross Monthly Income)	How often received?
1
2
3
4
5
6
7

Page 3 of 3 - DFCS Out of School Services Eligibility Form
Name of Parent/Guardian/Caregiver (Last, First, MI)
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Home Phone
Work #
Cell
Parent/Caregiver/Guardian Printed Name
Date

MonthDayYear
Date
Parent/Caregiver/Guardian Signature

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Page 1 of 2 - DFCS Out of School Services Eligibility Form Appendix
Page 2 of 2 - DFCS Out of School Services Eligibility Form Appendix
Georgia Division of Family and Children Services Well-Being Services Section Out of School Services
NON-INCOME DECLARATION FORM
I, Mr. /Mrs. /Ms.
Parent and/or guardian of
hereby declare that I do not have any income at this time.

I have not received income from any of these sources:
- Wages from employment (Ex: commissions, tips, bonuses, fees etc
- Rental income from the place I live or other property I own
- Interest of dividend from assets
- Social Security payments (including SSA or SSI), annuities, insurance policies, retirement funds, pension, or death benefits
- Unemployment or disability payments
- Public Assistance payments (Ex: TANF)
- Child support, alimony or gifts received from persons not living in my household
- Any other source not named above
I swear, under penalty of perjury, that to the best of my knowledge, all the information and statements I’ve provided in this application are true, and I promise to cooperate with any effort to verify the information provided.
Signature of Parent/Guardian

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Girls Inc. of Greater Atlanta DFCS Out of School Services Registration Form
SECTION I: CHILD’S PERSONAL INFORMATION
Name

A.Legal Last NameB. Legal First NameC.Legal Middle Name
D.Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
E.Age
F. Gender

MaleFemaleOther
G. HomeAddress
H. P.O.Box/Apt#
I. City
J.State
K.Zip
L.Home Phone Number
M.Alternate Phone Number
SECTION II: CHILD’S SCHOOL INFORMATION
A. Grade Level(upcoming schoolterm)
B. School Attending
C. Is the student an ESOL* student:

YesNo
SECTION III: CHILD’S DEMOGRAPHIC INFORMATION
A. Ethnicity

Black, Non-HispanicHawaiian Native/Pacific IslanderWhite, Non-HispanicAlaska Native/American IndianAsianHispanic/LatinoOther
B. Is thestudent aspecial needsstudent?

YesNo
If yes, please specify the child’s special need(s)
SECTION IV: CHILD’S HOUSEHOLD INFORMATION
A. Participant Lives With:

One parentGroup HomeBoth parentsGrandparentsGuardian/CaregiverFoster HomeOther
B.How many people are in your household?
SECTION V: PARENT/GUARDIAN DECLARATORY STATEMENT
I (print name)
certify that all the information given in this form is correct and true to the best of my knowledge. I understand that providing false information may result in my child not being able to participate in Out of School Services.
Parent or Guardian Signature

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Page 1 of 2

Georgia Division of Family & Children Services
Well-Being Services Section
Out of School Services

Parental Permission for Photo Release

Page two of this document requests your permission for the Georgia Division of Family and Children Services (DFCS) to take and use photographs of your child and other Out of School Services staff. When we tell others the story about DFCS Out of School Services, it would be helpful to share photographs of the statewide participants. Pictures can enhance people’s understanding about who is involved in the program and what activities and services are being conducted. If you have more than one child, this form should be completed for each child participating in DFCS Out of School Services.

If you agree for us to take and use these photographs, our use of them will include, but will not necessarily be limited to the following: publications about the program; recruitment activities to reach additional youth who might participate in the future; and/or reports about the program to supporters and others who are interested in the program’s outcomes.

If you have any questions regarding the Photo Release Form, please contact DFCS Out of School Services at 404-657-4651.
Photo/Video

Release Agreement

COBB County, Georgia

School/Organization Name: Girls Inc. of Greater Atlanta

1. I, the undersigned, consent and agree that still photographs, motion pictures, or television presentations in the form of either live or video tape may be made of myself, my child (ren) by the Georgia Division of Family and Children Services.

2. This release gives the Georgia Division of Family and Children Services the right to use the above-listed visual material in conjunction with the teaching, instruction, training, information, and education of employees of the Department or the general public.

3. Further, I hereby release the Georgia Division of Family and Children Services and forever discharge any claim of any nature against them as long as the material is used in compliance with the above-stated paragraph 2.

4. I grant this consent as (parent-guardian) a voluntary contribution in the interest of the said reasons listed in paragraph 2.

5. I understand this Photo/Video Release Agreement does not apply to children in foster care. I further understand if my child is in the foster care system within Georgia, they are not allowed to be photographed or included in motion pictures or television.
Parent/Guardian Name
Parent/Guardian Address
Parent/Guardian Telephone
Photo Description: Participation in DFCS funded Out of School Services activities.

Children Participating in Program:
Name
Age
Name
Age
Name
Age
Parent/Guardian Signature

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Date
Photographer or producer or witness:
Georgia Division of Family & Children Services
Well-Being Services Section
Out of School Services

Participant Medical Information Form – Page 1
(To be maintained on site for each participant)
STUDENT INFORMATION
Legal Name of Child (Last, First)
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Age
Sex (check one):

MaleFemale
Street Address
Home Phone No:
P.O. Box/Apt #
City
State
Zip Code
INSURANCE INFORMATION
Does the child have health insurance coverage?

YesNo
Name of insurance provider (if applicable)
MEDICAL INFORMATION
Does the child have any allergies?

YesNo
If yes, please list them:
Does the child have any other medical conditions (disabilities, infections, viruses, diseases, etc)?

YesNo
If yes, please list them:
Is the child currently taking any medications (prescribed and non-prescribed)?

YesNo
If yes, please list them:
IN CASE OF EMERGENCY
Contact Name
Relationship to youth
Home Phone Number
Work Phone Number
Alternate Contact Name
Relationship to youth
Home Phone Number
Work Phone Number
PLEASE SIGN PAGE 2 TO VERIFY THE INFORMATION PROVIDED
Participant Medical Information Form – Page 2
By signing below, I certify the above information is true to the best of my knowledge. I authorize Girls Inc. of Greater Atlanta to contact me if my child is injured and/or harmed in any way. I also authorize Girls Inc. of Greater Atlanta seek medical attention for my child if he or she is injured and/or harmed and needs immediate medical assistance at a local hospital or emergency care center. I certify that I and/or our family’s insurance provider will be responsible for any financial medical costs that may be associated with all medical attention and treatment given to my child. In consideration of their granting my child the opportunity to participate in Out of School Services. I hereby release, indemnify, and hold harmless the Division of Family and Children Services and Girls Inc. of Greater Atlanta from any liability, claim or demand resulting from any legal medical attention and assistance that may be needed and provided as a result of an injury or harmful incident to my child.
Legal Name of Parent (print)
Signature

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