Weekend STEM Club Registration Form

Weekend STEM Club Registration Form
Please fill out all information below:
Member Information
Girl's Name
Date of Birth

MonthDayYear
Date
Age
Grade
School
T-shirt Size
Parent Email Address
example@example.com
Parent Phone Number
Emergency Information
Emergency Contact Name
Emergency Contact Phone Number
Is anyone in your household currently incarcerated?

YesNo
Permission Form
I understand that staff will keep information disclosed in the course of this program confidential unless they feel it needs to be reported to the school or other agencies to protect the safety and best interest of the participant or those around the participant.

I give permission for my child to be photographed and for those pictures or materials she creates to be used for marketing purposes of Girls Inc. and their partners. I also give permission for my child to participate in evaluations as part of the Girls Inc. program including pre-and post-program surveys.
Girl’s Name
Parent/Guardian’s Name
Signature

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Date

MonthDayYear
Date
If you have further questions or concerns about the program, please feel free to contact Kate Sherrill at 770-422-0999, ext. 206.

Girls Inc. would like to stay in contact with you and your child for the purposes of involving you in future programming opportunities. Including our annual scholarships awarded exclusively for girls who had gone through our programs and special field trips, workshops and future programs. In additon, we hope to stay in touch to see how Girls Inc. girls succeed in the future!

The information you provide will not be used by anyone outside of Girls Inc.
Should be Empty:

Weekend STEM Club Registration Form

Member Information

Emergency Information

Permission Form