KIPP Afterschool Registration Form 2025-2026

KIPP Afterschool Registration Form
*Accepting participants from K-8th*

Please fill out all information below:
Afterschool Dates
August 2024 through May 2025
Monday-Thursday: 3:45pm-6:30pm
Friday: 1:45pm-6:30pm

*Girls Inc. will be closed during specific holidays.
Please contact your site staff for details.
Choose your location:

KIPP VisionKIPP Ways
Participant's Information
First Name*
Last Name*
Age*
Grade*
Gender*
T-shirt Size*
Participant's email address (if applicable)
example@example.com
Participant's phone number (if applicable)
Parent and/or Guardian Information
Parent/Guardian’s Name
Address

Street Address

Street Address Line 2

CityState

Zip Code
Parent/Guardian’s email address
example@example.com
Parent/Guardian’s phone number
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 child’s participation in the program.
Demographics
1) What languages(s) is spoken in your home?

EnglishSpanishOther
2) Is the Head of Household a female?

YesNo
3) Is someone in the household currently receiving: (check all that apply)

Food StampsTANFMedicaidSSDISSIFree/Reduced School Lunch
4) Please provide your income level:

$0 – $10,000$10,001 – $20,000$20,001 – $30,000$30,001 – $50,000Over $50,000
5) How many people are in your household?
6) Ethnicity:

Black, Non-HispanicWhite, Non-HispanicHispanic/LatinoAsianHawaiian Native/Pacific IslanderAlaska Native/American IndianOther
7) Participant lives with:

One ParentGroup HomeBoth ParentsGrandparentsGuardian/CaregiverFoster HomeOther
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.

Bright from the Start Notice of Exemption
I acknowledge that I have been informed that this program is not licensed. I also understand this program is not required to be licensed by Georgia Department of Early Care and Learning and this program is exempt from state licensure requirements.
Parent/Guardian’s Signature:

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Date
Authorization Agreement
I,
hereby authorize Girls Inc. of Greater Atlanta to automatically deduct $40 weekly from my account for program fees during the 2024-2025 school year. I acknowledge that this authorization is mandatory for participation in the Girls Inc. of Greater Atlanta afterschool program.

Permission Form
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.
Participants’s Name
Parent/Guardian’s Name
Signature*

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Date*

MonthDayYear
Date
If you have further questions or concerns about the program, please feel free to contact Cathy Anderson at 678-686-1740, ext. 229 or at canderson@girlsincatl.org.

The information you provide will not be used by anyone outside of Girls Inc.

Girls Inc. would like to stay in contact with you and your child for the purposes of involving you in future programming opportunities.
Emergency Treatment Permission
Please provide the best way to reach you, as well as any relevant information that staff may need to know in an emergency.
I
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.
Participant's Name
Parent/Guardian's Name
Relationship to Participant
Signature*

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Date*

MonthDayYear
Date
Contact Number 1
Contact Number 2
Additional Emergency
Contact Name
Relationship to Participant
Contact Number 1
Contact Number 2
Additional Emergency
Contact Name
Relationship to Participant
Contact Number 1
Contact Number 2
Insured Name
Insured Birthdate

MonthDayYear
Date
Medical Insurance
Group Number
Policy Number
Other relevant emergency information (medicine allergies, specific instructions, etc.)
Field Trips/Special Events Permission Form
I
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.
Participant's Name
Parent/Guardian's Name
Relationship to Participant
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
Contact Number 1
Contact Number 2
Media Consent and Release Form
I,
, parent/guardian of
give permission for my childto be photographed, videotaped, and/or interviewed by Girls Inc. of Greater Atlanta o r our partners for program documentation, marketing, and promotional materials. Participant agrees to allow himself or herself to be photographed or recorded in other media, such as video or audio recordings, in connection with the Afterschool Program or other activities or events of Girls Inc. Participant understands and agrees that the photographs and/or other media recordings may be used to promote Girls Inc., its services and events. Participant hereby irrevocably grants and conveys unto Girls Inc. all right, title and interest in any and all photographic images and other media recordings taken during the Afterschool Program or other activities and events of Girls Inc., including, but not limited to, any royalties, proceeds, or other benefits derived from such photographs or other media recordings.
Participant understands and agrees that Participant is waiving all rights to privacy and ownership regarding the use of such photographs and other media
recordings.
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
Social & Emotional Wellness Questionnaire
Girls Inc. of Greater Atlanta is committed to supporting the overall health of our participants and families that includes the well being of their emotional and mental health. Through this questionnaire, we are focused on developing programs
that supports our participants at every level and stage of their adolescent development. Helping them to learn and implement healthy coping skills, impulse control, anger management and build self-esteem.

Please know that all information that is provided is subject to strict HIAA confidentiality rules and guidelines. Only authorized personnel within Girls Inc. Greater Atlanta will have access to this information, unless written consent is given
by a parent/legal guardian.
Student’s Name
Age
Grade
Has your child experienced bullying in the last six month?

YesNo
Explain
Has your child experienced any anxiety and/or depression in the last six month?

YesNo
Explain
Has your child experienced a traumatic situation in the last six months?

YesNo
(If so, please explain)
Has your child expressed thoughts of harming themself or anyone else in the last six months?

YesNo
Explain
Has your child received therapy or any other mental health services in the last six months?

YesNo
(if yes, is your child still receiving therapeutic support)
Has your child received a mental health diagnosis in the last 2 years?

YesNo
(if so, please explain)
Has your child been hospitalized in the last six months?

YesNo
Explain
Has your child been prescribed medication to help address their emotional, mental and/or behavioral healt hneeds in the last six months?

YesNo
(if yes are they taking are they taking the medication asinstructed
Is there anything that you would like to share with us about your child’s emotional and/or mental health?
DFCS Eligibility Form Instructions
Please read instructions below before completing DFCS Eligibility Form
Instructions on completing the following sections:
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).
OR
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).
OR
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).
OR
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).
OR
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.
OR
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 -
DFCS Eligibility Form Instructions
DFCS Eligibility Form Instructions

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
Georgia Division of Family and Children Services

Out of School Services
Youth Participation Eligibility Form

Page 1 of 3 - DFCS Out of School Services Eligibility Form

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.
Name of Youth Participant (Last)
(First)
(MI)
Social Security Number
Gender:

MaleFemale
Date of Birth (mm/dd/yy)

MonthDayYear
Date
Is the youth named above in Foster Care within the state of Georgia

YesNo
Note: If the youth is in Foster Care but not in the care of Georgia, please provide the state name
Section 1
A. Is the youth applicant a U.S. citizen or qualified alien?

YesNo
B. Is the youth applicant a Georgia resident?

YesNo
C. Does the youth applicant fall into one (1) or more of the three categories below (Answer YES or NO and check all categories below that apply to the youth)?:

YesNo
Youth applicant is between the age of 5 and 17 years old; ORYouth applicant is 18 years old and currently enrolled in school (high school, GED program or equivalent, or post secondary institution) and will be enrolled in AND ttend school during the upcoming academic year (Verification of school enrollment includes a letter from the school on official school letterhead): ORYouth applicant is 18 - 19 years old and has a dependent child AND is the custodial parent
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.
Section 2
Does the youth currently receive benefits or services under any of the programs listed below (Please Note: you will have to provide official verification to the out of school services program. See Appendix C for acceptable forms of verification):
A. Temporary Assistance for Needy Families (TANF)

YesNo
B. Supplemental Nutrition Assistance Program (SNAP) (also known as Food Stamps)

YesNo
C. Medicaid or Social Security Income (SSI)

YesNo
D. This is not applicable if the entire school population is awarded free lunch in universal eligibility. Note: This eligibility is only for single youth eligibility.

YesNo
E. Peachcare for Kids

YesNo
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.
Page 2 of 3 – DFCS Out of School Services Eligibility Form
Section 3
If you answered NO to ALL of the questions in Section 2, please review the chart below and enter your family unit size, gross household yearly income and gross household monthly income to determine eligibility.
DFCS Out of School Services Family Income Eligibility Guide
Family Unit Size*
Gross Household Yearly Income $
Gross Household Monthly Income $
* See Appendix A for definition of family unit.
Section 4
Please complete Section 4 by listing your name, the name of the child (ren) who live with you, and the other parent of the child (ren) if s/he lives with you. List any gross monthly income for each.
Household Composition and Income
Gross Monthly Income is income before taxes and deductions.

Relationship

	Name (First, Middle, and Last)	Relationship	Date of Birth (MM/DD/YY)	Income Source	Amount (Gross Monthly Income)	How often received?
1
2
3
4
5
6
7

Page 3 of 3 - DFCS Out of School Services Eligibility Form
Section 5

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

Applicant Notification and Signature

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.
Name of Parent/Guardian/Caregiver (Last, First, MI)
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Home Phone
Work
Cell
Parent/Caregiver/Guardian Printed Name
Date

MonthDayYear
Date
Parent/Caregiver/Guardian Signature*

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Date*

MonthDayYear
Date
By signing below, I certify the information presented within this form was reviewed, verified and confirmed** and meets the DFCS Out of School Services Eligibility rules and guidelines indicated within this form. I also certify this form will be kept in the youth participant’s file in a confidential and secured location.
Page 1 of 2 - DFCS Out of School Services Eligibility Form Appendix

APPENDICES

*Appendix A: Family Unit

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.
**Appendix B: Income Proof Sources and Applicable Income Sources

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;
- Employer’s 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.
Page 2 of 2 - DFCS Out of School Services Eligibility Form Appendix

Applicable Income

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
**Appendix C: Acceptable Verification of Benefits or Services
- Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid, and
  Peach Care: 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, schoolwide, city-wide or district-wide free lunch does not qualify as an acceptable point of eligibility for DFCS Out of School Services.
Georgia Division of Family and Children Services Prevention and Community Support (PCS) Out of School Services
NON-INCOME DECLARATION FORM
I, Mr. /Mrs. /Ms.
Parent and/or guardian of
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.
Signature of Parent/Guardian*

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Date*

MonthDayYear
Date
Girls Inc. of Greater Atlanta

DFCS PCS Out of School Services Registration Form

SECTION I: CHILD’S PERSONAL INFORMATION
Name

A.Legal Last NameB.Legal First NameC.Legal Middle Name
D. Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
E. Age
F.Gender

MaleFemaleOther
G.Home Address
H. P.O. Box/Apt #
I. City
J.State
K.Zip
L.Home Phone Number
M.Alternate Phone Number
SECTION II: CHILD’S SCHOOL INFORMATION
A. Grade Level (upcoming school term)
B. School Attending
C. Is the student an ESOL* student:

YesNo * English as a second language
SECTION III: CHILD’S DEMOGRAPHIC INFORMATION
A.Ethnicity

Black, Non-HispanicHawaiian Native/Pacific IslanderWhite, Non-HispanicAlaska Native/American IndianAsianHispanic/LatinoOther - Specify
B. Is the student a special needs student?

YesNo
If yes, please specify the child’s special need(s)
SECTION IV: CHILD’S HOUSEHOLD INFORMATION
A.Participant Lives With

One parentGroup HomeBoth parentsGrandparentsGuardian/CaregiverFoster HomeOther
B. How many people are in your household?
SECTION V: PARENT/GUARDIAN DECLARATORY STATEMENT
I (print name)
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.
Parent or Guardian Signature

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Date
Page 1 of 2

Georgia Division of Family & Children Services
Prevention and Community Support
Out of School Services

Parental Permission for Photo Release

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.
Georgia Division of Family & Children Services

Prevention and Community Support

Out of School Services

Photo/Video Release Agreement

Dekalb 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.

5. I understand this Photo/Video Release Agreement does not apply to children in foster care. I further understand if my child is in the foster care system within Georgia, they are not allowed to be photographed or included in motion pictures or television.
Parent/Guardian Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Telephone
Photo Description: Participation in DFCS funded Out of School Services activities.

Children Participating in Program:
Name
Age
Parent/Guardian Signature*

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Date*

MonthDayYear
Date
Photographer or producer or witness
Georgia Division of Family & Children Services Prevention and Community Support Out of School Services
Participant Medical Information Form – Page 1 (To be maintained on site for each participant)
STUDENT INFORMATION
Legal Name of Child (Last, First)
Date of Birth (MM/DD/YYYY)

MonthDayYear
Date
Age
Sex (check one):

MaleFemale
Street Address
Home Phone No:
P.O. Box/Apt #
City
State
Zip Code
INSURANCE INFORMATION
Does the child have health insurance coverage?

YesNo
Name of insurance provider (if applicable)
Does the child have any allergies?

YesNo
If yes, please list them:
Does the child have any other medical conditions (disabilities, infections, viruses, diseases, etc)? If yes, please list them:

YesNo
If yes, please list them
Is the child currently taking any medications (prescribed and non-prescribed)?

YesNo
If yes, please list them
IN CASE OF EMERGENCY
Contact Name
Relationship to youth
Home Phone Number
Work Phone Number
Alternate Contact Name
Relationship to youth
Home Phone Number
Work Phone Number
PLEASE SIGN PAGE 2 TO VERIFY THE INFORMATION PROVIDED
Participant Medical Information Form – Page 2
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.
Legal Name of Parent (print)*
Signature*

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Date
Should be Empty:

KIPP Afterschool Registration Form

Participant's Information

Demographics

Authorization Agreement

Emergency Treatment Permission

Additional Emergency

Additional Emergency

Field Trips/Special Events Permission Form

Media Consent and Release Form

Social & Emotional Wellness Questionnaire

DFCS Eligibility Form Instructions

DFCS Eligibility Form Instructions

Section 1

Section 2

Page 2 of 3 – DFCS Out of School Services Eligibility Form

Section 3

DFCS Out of School Services Family Income Eligibility Guide

Section 4

Household Composition and Income

Page 3 of 3 - DFCS Out of School Services Eligibility Form

Section 5

Georgia Division of Family and Children Services Prevention and Community Support (PCS) Out of School Services

SECTION II: CHILD’S SCHOOL INFORMATION

SECTION III: CHILD’S DEMOGRAPHIC INFORMATION

SECTION IV: CHILD’S HOUSEHOLD INFORMATION

SECTION V: PARENT/GUARDIAN DECLARATORY STATEMENT

Georgia Division of Family & Children Services Prevention and Community Support Out of School Services

STUDENT INFORMATION

INSURANCE INFORMATION

IN CASE OF EMERGENCY

PLEASE SIGN PAGE 2 TO VERIFY THE INFORMATION PROVIDED

Participant Medical Information Form – Page 2