Hidden

Embedded Page Title(Required)

Student Name(Required)

First Middle Last

Student Nickname

Student Email Address

Student Gender(Required)

Student Date of Birth(Required)

Student Primary Address(Required)

Street Address Address Line 2 City State ZIP Code

Family Configuration:(Required)

Two Parent Home

Shared/Joint Custody

Mother Only

Father Only

Single Parent

Foster Parent(s)

Grandparent(s), Guardian(s), Other Relative(s)

Unknown

Other

What school will the student be attending in the Fall?(Required)

Student Grade Level in Fall(Required)

Please select the grade level that the participant will be in Fall.

Student Primary Language(Required)

Student Race & Ethnicity(Required)

American Indian Alaska Native

Asian

Black/African American

Hispanic or Latino

Native Hawaiian/Pacific Islander

Middle Eastern/North African

White

Multiracial

Other

Has the student been involved in previous Girls Inc. programs?(Required)

Yes

No

Unsure

Is this student presently under doctor’s care?(Required)

Yes

No

Name of Doctor(Required)

Doctor Phone(Required)

What kind of medical condtion?(Required)

Does this student take any prescribed medications?(Required)

Yes

No

Please describe any side effects(Required)

Does this student use any medical device(s) at home?(Required)

Yes

No

What kind of device(s)?(Required)

List any allergies and describe allergic reactions

Does this student have any special needs or need any accommodations?

As the parent/guardian of the above named student, I, the undersigned, assert that the information above is true and correct and understand that at a Girls Inc. of Orange County Program, physical activity is a regular part of the program. To the best of my knowledge, my student is in excellent physical health and needs no restrictions (except what is listed above) from strenuous activity. If I have any questions regarding my student's health, I understand that is my obligation to seek professional medical advice and to inform Girls Inc. of Orange County of any restrictions on my student's activities.(Required)

I understand

As the parent, authorized representative, or legal guardian, I hereby give Consent to Girls Inc. of Orange County to provide emergency dental or medical care prescribed by a duly licensed physician (M.D.) dentist (D.D.S.) or osteopath (D.O.) for the above name student. This care may be given under whatever conditions are necessary to preserve life, limb or well being of the student above.(Required)

I understand

Primary Parent/Guardian Name(Required)

First Last

Primary Parent/Guardian Relationship to Student(Required)

Father

Mother

Legal Guardian

Primary Parent/Guardian Email Address(Required)

Enter Email Confirm Email

Primary Parent/Guardian Address(Required)

Same as Student

Street Address Address Line 2 City State ZIP Code

Primary Parent/Guardian Phone(Required)

Primary Parent/Guardian Alternative Phone

Add a Secondary Parent/Guardian?(Required)

Select Yes to Add another Parent/Guardian.
Select No to continue.

Yes

No

Secondary Parent/Guardian Name(Required)

First Last

Secondary Parent/Guardian Relationship to Student(Required)

Father

Mother

Legal Guardian

Secondary Parent/Guardian Address(Required)

Same as Student

Street Address Address Line 2 City State ZIP Code

Secondary Parent/Guardian Email Address(Required)

Enter Email Confirm Email

Secondary Parent/Guardian Phone(Required)

Secondary Parent/Guardian Alternative Phone

Emergency Contact List

Name

Phone

Relationship

In the event that the primary parent(s)/guardian(s) are unable to pick up the student or in the case of an emergency, I authorize the following adult to be contacted.

More information about each program is located on our Summer Programs page.

Terms & Conditions(Required)

I, the undersigned parent/guardian of the participant, hereby consent to the participant's membership in Girls Inc. of Orange County. I understand that Girls Inc. is a youth service organization that offers research-based programs for girls throughout Orange County. I understand that Girls Inc. of Orange County will conduct research about the impact of its programs for girls. I agree to allow my child to take part in pre/post testing and other evaluation efforts All information regarding girls or their participation in programs will be confidential. If my daughter is accepted into Girls Inc. programming, I will encourage her to participate fully in all activities and see that she regularly attends during program time and that proper forms are completed and returned on time. I will support her by attending the Parent-Guardian/Participant Orientation. I will allow photographs, audio and video recordings of the participant while involved in program activities to be taken by a Girls Inc. staff or outside media, authorized by Girls Inc., for publicity purposes (such as but not limited to: brochures, websites, social media and newsletters). I understand that participation in in-person programming includes possible exposure to and illness from infectious diseases including but not limited to COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks related to illness and infectious diseases, such as COVID-19, even if arising from the negligence or fault of Girls Inc. of Orange County and its principals and agents; and I hereby knowingly assume the risk of injury, harm and loss associated with the Activity, including any injury, harm and loss caused by the negligence, fault or conduct of any kind. I further understand that should my child/participant become exposed to COVID-19, either directly or indirectly, I will notify the Girls Inc. of Orange County team and my child/participant will not attend the in-person events/programming. Additionally, should my child/participant display any symptoms or changes associated with COVID-19, I will notify Girls Inc. of Orange County staff and my child/participant will not attend the in-person events/programming. In the event of an emergency, I hereby authorize Girls Inc. of Orange County to carry out any measures deemed necessary, including securing medical care for the participant at the expense of the undersigned. I release Girls Inc. of Orange County, its employees and agents, from any and all liability arising from the participant's membership and participation at Girls Inc. of Orange County. By entering your name below, you are effectively providing your signature, indicating that you provide permission and consent for your daughter to participate in the Girls Inc. of Orange County virtual programming.

I agree to the Terms & Conditions

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Eureka! Anaheim High School – (June 3rd – 28th)

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