Girls Empowerment After-School Program

Participate Information

Childs Name

First NameLast Name

Birth Date

MonthDayYear

Age

Grade

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Home Number

Area CodePhone Number

Cell Number

Area CodePhone Number

E-mail

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Payment to be made via etransfer to : Sharon@simplyanewme.com or Cash on the start of the program.

Registration Fee: $50

Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the child prescribed an inhaler? If yes, please explain any instructions.

Is the child allowed to go home alone?

Who will pick up your child?

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Simply Anew Me during the selected camp. In exchange for the acceptance of said child’s candidacy by Simply Anew Me ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Simply Anew Me . 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 camp sessions.

In case of injury to said child, I hereby waive all claims against Simply Anew Me including all affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Payment to be made via etransfer to : Sharon@simplyanewme.com or Cash on the start of the program.

Registration Fee: $50

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.

Signature

Girl Empowerment Afterschool Program Registration Form 2026