I Believe in Me Girls Registration Form

I Believe in Me Girls Registration Form

2026-2027 Mentoring Year
Participant Status
Participant Name

First NameLast Name
Age
Date of Birth

MonthDayYear
Date
Participant Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
School
Grade Level (2026-2027 school year)
T-Shirt Size (Unisex)
Race/Ethnicity (Select all that apply)
Does the child have any allergies?
Does the child have any special needs or medical conditions that we should be aware of?
Parent/Guardian Information
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Relationship to Participant
Emergency Contact Information (other than parent listed above)
Emergency Contact

First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Program Selection
Preferred Meeting Location
How did you hear about IBIM Girls?

Other
Payment Details

$30.00

Total

Permission & Release Forms
Photo, Video & Media Release
I hereby grant permission to I Believe in Me Girls (IBIM Girls), its employees, volunteers, representatives, partners, and affiliates to photograph, videotape, record, and use images, likenesses, voice recordings, and statements of my child during program activities, events, workshops, filed trips, and related functions.

I understand that these photographs, videos, and recordings may be used for educational, promotional, marketing, fundraising, social media, website, newsletter, grant reporting, and other organizational purposes without compensation. I understand that my child's name will not be published without additional consent.
Media Release Permission
Parent/Guardian Signature
Date Signed

MonthDayYear
Date
Should be Empty:

Parent/Guardian Information