Girl Code Academy Interest Form

Girl Code Academy Interest Form

Please complete this form to express your interest in enrolling your child in Girl Code Academy and to help us understand your preferences and needs.
Parent/Guardian Information

Please provide your contact details.
Full Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Participant Information

Tell us about your child.
Child’s Name

First NameLast Name
Child’s Age
School Name
Grade Level
Are you interested in enrolling your child in Girl Code Academy?
How did you hear about Girl Code Academy?

Other
Which monthly empowerment sessions are you interested in?
Preferred session time:
Does your child have any allergies or medical needs we should be aware of?

Yes
Will your child need transportation assistance?
Pickup Location (if transportation assistance is needed)
Would you like to receive volunteer or partnership opportunities?
What are your hopes for your child during Girl Code Academy?
Consent: Please review and confirm the following statements.

By submitting, you confirm your understanding and agreement.
I consent to photos/video for program documentation and promotional use.
Signature (Parent/Guardian Name)
Date

MonthDayYear
Date
Should be Empty: