New Customer Registration Form

Participants Health Information
Allergies to food: If none/unknown please type "N/A"*
Allergies to medicine: If none/unknown please type "N/A"*
Other allergies: If none/unknown please type "N/A"*
Special Disabilities: (Check all that apply)

LearnigDevelopmentalEmotionalVisualHearingMobilityNone/UnknownOther Special Needs
Any other information you would like to provide regarding participants health
Participants Medical Information
Medical Insurance Provider*
Coverage number*
Physician Name
Dentist Name*
Dentist number*
Parent/Guardian-Please read and sign: I give my permission to obtain all emergency medical or dental care prescribed by a duly licensed Physician (M.D) Osteopath (D.O) or Dentist (D.D.S.) for my child. This care may be given under whatever conditions are necessary to preserve the life, limb or well being of the child named above. Please date and sign below.
Signature*

Clear

Participants Emergency Contact Information

In addition to the parent/guardians, the following adults (18 years and older) are authorized to take this child from the this facility. These names will also serve as emergency contacts. These contacts must be reachable and available for immediate pick-up or response.
Emergency Contact 1*

First NameLast Name
Relationship to participant *
Phone Number*
Please enter a valid phone number.
Emergency Contact 2

First NameLast Name
Relationship to participant
Phone Number
Please enter a valid phone number.
Court Filings

DO NOT RELEASE - My child should NEVER be released to the following named people based on court documents.
My child should never be released to:
Please provide any additional information as needed.

Media/Social Media Release

I hereby authorize Girl Inc. of the Island City, its agents and others working for it or on its behalf to use my daughter’s image/likeness/voice/artwork/writing in still photos, slides video productions on Girls Inc. of the Island City’s accounts on social media sites (Facebook, Twitter, etc) including Girls Inc. website, for promoting and representing Girls Inc. and its programs, and do hereby grant and convey unto Girls Inc. all rights, title, and interest in the above media including but not limited to, any royalties, proceeds, or other benefits derived from such photographs or recordings.
YES- I grant my permissionNO- I do not grant my permission
Signature*

Clear
Liability Agreement Release (required for participation)

I hereby authorize, as parent or legal guardian, for my girl to participate in Girls Inc. Programs. In consideration for this participation, I do hereby, for myself and my heirs and assigns, release and agree to indemnify and hold harmless Girls Incorporated of the Island City, its employees and volunteers from all liability, loss, claim, demand, action or cause of action which arises or may arise or be occasioned in any way by such participation. I also release and hold harmless Girls Inc of the Island City, its employees and volunteers from all liability, loss or claim which may occur in transporting my child for the purposes of participating in any Girls Inc. activities.
Yes, I agree to the Liability Agreement Release*

Yes
Signature*

Clear