Summer Camp Detailed Registration Form

Girl Goals Summer 2025 Program Registration
Girl Information*

First NameLast Name
Birth Date

MonthDayYear
School
Grade entering in September 2025
Grade entering in September 2025
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
This is a fill in the blanks field. Please add appropriate blank fields and text.
T-Shirt Size
Parent/Guardian Information
Parent 1

First NameLast Name
Home Number
Cell Number
Parent 2

First NameLast Name
Home Number
Cell Number
E-mail
example@example.com
Name & phone number of person(s) other than parents your child can be released to for pick up.

Any special intructions such as custody or retraining orders must be emailed to GirlGoals@sayeghcivic.org and discussed personally with the director. All information will be kept confidential.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Emergency Contacts

Every effort will be made to contact the Parents/Guardians first:
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Alt. Phone Number
Medical Information
Health Care Provider
Physician

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Medical Insurance Information

Insurance CompanyPolicy Number
Does your child have any allergies, food allergies or restrictions, chronic illness, or medical conditions? If yes, please describe.
Does your child have prescribed an inhaler, EpiPen or any prescribed medications? If yes, please explain any instructions.
Use the space below to provide any additional information about the child's behavior and physical, emotional, or mental health which would assist in providing your child the best program experience.
Medical Release and Authorization

As Parent and/or Guardian of the named, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named child. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Girl Goal Summer Program and its affiliates including Staff and Volunteers to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Informed Consent and Acknowledgement

I hereby give my approval for my daughter's participation in any and all program activities prepared by Girl Goals Summer Program including all weekly field trips and swimming at Lou Costello Pool. In exchange for the acceptance of said child's enrollment, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Girl Goals Summer Program and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected program sessions.

In case of injury to said child, I hereby waive all claims against the Girl Goals Summer Program including all staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Date

MonthDayYear
Date
Signature

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Girl Goals Summer 2025 Program Registration

Emergency Contacts

Medical Information

Health Care Provider