Program Registration Winter 2023/24
Please Complete Program Registration and Submit  
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电子邮件地址 *
Program you are registering for? *
Childs Name (First & Last) *
Child Date of Birth *
年
/
月
/
日
School and Grade *
Information you would like us to know: (special needs, allergies, custody arrangements, concerns) *
Address (Street Number/ Name, City, Postal code) *
Email To be used for Virtual Progams *
Parent/Guardian 1 (Relationship) Contact (Phone number, email) *
For Parent/Guardian Above? *
Yes
No
Authorized to pick up?
Emergency Contact
Primary Contact
Parent/Guardian 2 (Relationship) Contact (Phone number, email) *
For Parent/Guardian Above? *
Yes
No
Authorized to pick up?
Emergency Contact
Primary Contact
Emergency Contact 1 (Name, Relationship to child, phone number) *
We must be able to contact you in the event of a question, concern, pick-up issue, illness or other matter that requires immediate assistance. Parent(s) will always be contacted first.
Emergency Contact 2 (Name, Relationship to child, phone number) *
We must be able to contact you in the event of a question, concern, pick-up issue, illness or other matter that requires immediate assistance. Parent(s) will always be contacted first.
Household Type
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Racial/Ethnic Configuration
Family Income
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Language Spoken in the Home
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Payment Arrangements  *
I give permission for my child to participate in Girls Incorporated discussions, activities, and
periodic evaluations. In case of medical or surgical emergency, I understand every effort will be
made to contact me. In the event that I cannot be reached, I hereby authorize and give consent to
Girls Incorporated of Upper Canada and its employees, agents, and contractors to obtain medical
assistance including first aid, proper treatment, transport and hospitalization if required. Girls
Incorporated of Upper Canada does not provide any accidental death, disability, dismemberment,
or medical expenses insurance on behalf of participants. I understand that the staff of Girls Inc.
reserves the right to suspend or refuse service, if, in their sole opinion, the behavior of a participant
puts her safety, or the safety and well-being of others, at risk.

Personal information gathered by Girls Inc. is kept in confidence. Information is not disclosed or
shared more widely than is necessary to achieve the purpose for which it was gathered. We
collect, use and disclose personal information only for statistical purposes.
Photo Permission *
I give permission and legal right to Girls Incorporated of Upper Canada for the use and ownership of any photographs, written or audiovisual material of the child for publicity and promotional purposes including but not limited to newsletters, brochures, annual reports, websites, radio, television, and newspapers.
Name of Legal Guardian Digital Signature *
By providing you name below I have read and agree with all  terms above:
您回复的副本将通过电子邮件发送到您提供的地址。
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