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Girls Inc. Holiday Workshop
Event Timing: December 9, 2023
Event Address: 301 Sulphur Springs Rd. Morristown, TN 37813
Contact us at (423)581-4430 or mgrahamstapleton@girlsinchamblencounty.org
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Camper Name
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Date of birth
MM
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DD
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YYYY
School
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Grade
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Registering Parent/Guardian Name
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Cellphone
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Email
*
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Address
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City
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State
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Zip Code
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Camper Lives with:
Both Parents
Mother only
Father only
Joint Custody
Grandparents
Foster Parents
Other:
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Your relationship to the child
Mother
Father
Step-parent
Sibling
Grandparent
Foster Parent
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Can we text you with updates about the program?
Yes
No
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Who else other than you can pick up the child from camp? Please list name and phone number.
Example: Jane Doe, 423-123-4567
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CAMPER HEALTH INFO: Please list food or other allergies; seasonal allergies; chronic illness; etc. Please note: We can NOT administer medicine other than basic first aid.
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DEMOGRAPHICS
This information is collected to assist our grantor in determining funds for programs in this community so we appreciate you filling out this section. Your information remains private and is seen only by the granting organization. Thank you!
Race
White
Black
Hispanic/Latina
Multiracial
Middle-Eastern
Asian-American
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Other:
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Please select the range that best describes your family's income.
$0-$10,000
$10,000-$15,000
$15,000-$20,000
$20,000-$25,000
$25,000-$30,000
$30,000-$35,000
$35,000-$40,000
$40,000-$50,000
$50,000-$60,000
> $60,000
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PERMISSION TO PARTICIPATE: "I hereby declare that the information contained in this application for my camper is correct. Further, my child has my permission to participate in all activities of the Girls Inc. Holiday Workshop. I understand that pictures and/or video will be taken during activities and that Girls Inc. of Hamblen County may use these pictures or images with or without identifying the member for Girls Inc. media as well as local, regional, or national media unless stated otherwise in written form." Your typed name below stands in as signature.
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Date of Application Completion
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Pay $5 supply fee the day of the holiday workshop at Girls Inc. Cash only.
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