GirlCode After-School Program Parent Interest Form
Thank you for your interest in GirlCode! Please complete the form below to express interest in enrolling your daughter. A member of our team will follow up with additional details.
Student Information
Information about the student you’re enrolling
Name
First Name
Last Name
Birth Date
-
Month
-
Day
Year
Date Picker Icon
Gender
Please Select
Male
Female
Ethnicity
Please Select
African American
Hispanic/Latino
Asian
Caucasian
Native American/Alaskan
Hawaiian/Pacific Islander
Middle Eastern
Prefer not to answer
Other
Email Address
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Grade
School Attending
Parent/Guardian Information
Information about yourself you’re enrolling
Name
First Name
Last Name
Parent Email Address
example@example.com
Parent Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Back
Next
Are you interested in enrolling your daughter in the GirlCoded after-school program at Simple Vue Academy?
Yes, I would like to enroll
I would like more information first
What are you most interested in for your daughter?
Building confidence and self-esteem
Leadership development
Emotional intelligence and coping skills
Goal-setting and planning
Social skills and communication
A supportive environment for girls
Is there anything you would like us to know about your daughter or what you’re hoping she gains from GirlCode?
Consent & Next Steps
I understand this form is to express interest in the GirlCoded after-school program. I will be contacted with additional details regarding enrollment.
*
Yes
Submit
Should be Empty: