Eureka Registration Form

Please fill out all information below.

Parent and/or Guardian Information

To help us keep these programs available, Girls Inc. must raise funds from a variety of

donors. Please help us in this effort by answering the following questions. This information will only be shared as an aggregate number (i.e. 50% of girls and will NOT affect your participant’s participation in the program.

I, the undersigned, certify that the information shown above is true and accurate to the best of my knowledge. I understand that I may be subject to criminal prosecution for knowingly providing false information to the agency.

I also agree to provide Girls Inc. with my participant’s school information which includes academic, attendance, and behavior records.

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.

If you have further questions or concerns about the program, please feel free to contact Cathy Anderson at 678-686-1740 or at canderson@girlsincatl.org. 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 participant's who have gone through our programs and special field trips, workshops and future programs. In addition, 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.

Please provide the best way to reach you, as well as any relevant information that staff may need to know in an emergency.

give permission for my 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 contacts listed below.

Other relevant emergency information (medicine allergies, specific instructions, etc.):

of , hereby give permission for my child to attend Girls Incorporated

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.

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: 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

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

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

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

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.

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

(Girls Inc. of Greater Atlanta), and the Georgia Division of Family and Children Services (DFCS) are partnering to provide valuable out-of-school programs for youth in Georgia. The information provided on this form will help ensure that eligible youth are benefiting from the partnership. Please complete this form in its entirety and return it to the identified staff person at the program site. We thank you for your cooperation.

Form to be completed by Parent/Custodian/Caregiver

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

If one (1) or more answers to the questions in Section 1 is NO, the youth IS NOT eligible to participate in the DFCS funded services. If the answer to ALL of the questions in Section 1 is YES, please complete the remainder of the form.

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.

*See Appendix A for definition of family unit.

Please review and sign Section 5 as notification and signature of verification.

• We are asking for your youth’s Social Security number because any person applying for or receiving federal benefits must give us his or her Social Security number. Federal law 409(a) (4) of the Social Security Act and federal regulations (45 CFR 264.10) allow us to collect this information. By signing this application,
• 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.
• If selected to participate in the program, I promise to abide by all rules and guidelines.

Parent/Guardian/Caregiver Information – This section must be completed in its entirety.

The Department of Human Services Temporary Assistance for Needy Families (TANF) definition of family includes the dependent child for whom assistance is requested and certain other individuals living in the home with the child who are required to be included in the family.

The following individuals are considered members of the Family Unit:

• A biological or adoptive parent of the dependent child for whom assistance is requested;
• An eligible minor sibling, (whole, half or adoptive) of the dependent child for whom assistance is requested;
• Other children living in the home who are within the specified degree of relationship to the grantee relative but who are not members of the Family Unit; and
• A non-parent relative who is the caretaker if there is no parent in the home or if the only parent in the home receives SSI.

Income verification must be obtained, and a copy must be attached to the youth’s income eligibility form.

Examples of earned income verification are:

• Pay stubs or receipts for the most recent four weeks of earnings;
• W-2 Forms;
• Employers issued, signed and dated documentation;
• Personal income ledger or tablet (e.g. self-employed)
• Quarterly income tax returns;
• Annual income tax returns when presented in January – March quarter;
• Letter/statement from employer;
• Documentation from other DFCS staff such as the eligibility CM; and/or
• Form 809 or itemized statement completed by the employer.

Examples of unearned income verification are:

• Copy of current check with check stubs (within last 4 weeks);
• Award letters or written, signed and dated statement of payer;
• Social Security Records;
• Worker’s compensation records;
• Form 139 – Contribution statement;
• Unemployment insurance claim records;
• Georgia Gateway screen information; and/or
• STARS.

See page 2 of Appendix B for applicable income sources.

Each of the following sources of income is budgeted in determining eligibility:

Earned

• Wages or salary – Gross income of the applicant is used to determine eligibility
• Net Income from Self-Employment
• Employee commission
• Jury Duty
• Rental Income – (regular and ongoing payments – if engaged in management of property for an average of 20 hours or more per week)
• Roomer Income – (regular and ongoing payments)

Unearned

• Military Allotments
• Cash gifts Charitable gift exceeding $300 received from and organization receiving state or federal funds
• Inheritances
• Insurance Benefits due to Loss of Income – benefits paid from an insurance policy due to loss of income
• Social Security Benefits
• Unemployment Compensation
• Worker’s Compensation
• Alimony – (regular and ongoing payments)
• Child Support – (regular and ongoing payments)
• Farm Allotment – payments received from government-sponsored programs, such as Agricultural Stabilization and Conservation Services
• Veteran’s Benefits
• Capital Gains
• Interest/Annuity
• Capital Gains/Dividends
• Pension
• Trust Fund
• Disability Payment
• Boarder Income – (regular and ongoing payments)
• Rental Income – (regular and ongoing payments - if engaged in management of property for an average of 20 hours or less per week)
• Deferred compensation through retirement plan

• Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid, and PeachCare: Official documentation showing the family/youth is currently receiving benefits at the time of application/enrollment into the Out of School Services Program (Integrated Eligibility System (IES) documentation, Official Letter from the Georgia Division of Family and Children Services outlining the receipt of benefits

• Supplemental Security Income (SSI): Award letter from the Social Security Administration

• Free or Reduced Lunch: Award letter identifying free or reduced lunch as established by individual family eligibility. Note: Programs may receive a listing of students receiving free or reduced lunch granted the listing is on official school letterhead with the disclaimer that all free or reduced lunch eligibility is determined by individual family application. Universal, school wide, city-wide or district-wide free lunch does not qualify as an acceptable point of eligibility for the DFCS Afterschool Care Program.

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.

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.

Page two of this document requests your permission for the Georgia Division of Family and Children Services (DFCS) Prevention and Community Support (PCS) to take and use photographs of your child and other Out of School Services staff. When we tell others the story about DFCS PCS 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 PCS 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 PCS Out of School Services at gadfcs.prevention@dhs.ga.gov.

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.

Children Participating in Program:

Participant Medical Information Form – Page 1 (To be maintained on site for each participant)

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.