Program Registration 2022

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Please Complete Program Registration and Submit

Email *

Untitled Title

Childs Name (First & Last) *

Child Date of Birth *

YYYY

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

Authorized to pick up?

Emergency Contact

Primary Contact

Parent/Guardian 2 (Relationship) Contact (Phone number, email) *

For Parent/Guardian Above? *

Yes

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

Father Only

Mother Only

Foster Parent

Grandparent/Other Relative

One Parent at a time (Joint Custody)

Two Parent

Other

Clear selection

Racial/Ethnic Configuration

Aboriginal

Arab

Asian

Black

Hispanic

Multi-Racial

White

Other

Family Income

Less the $10,000

$10,000-$20,000

$20,001- $30,000

$30,001- $50,000

Greater than $50,000

Clear selection

Language Spoken in the Home

English

French

Spanish

Other

Clear selection

Payment Arrangements *

E-transfer payable to admin@girlsinc-uppercanada.org

Calling the office with credit card 613-345-3295 x100

Cheque or cash on first day of programming

Full subsidy

Partial subsidy

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.

Yes

Name of Legal Guardian Digital Signature *

By providing you name below I have read and agree with all terms above:

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This form was created inside of Girls Incorporated of Upper Canada. Report Abuse

Forms