Enroll in the Girl Talk School & Site-Based Program!

Participant Information

Date of Application*

Girl's Full Name*

First Middle Last

Name of School or Site*

Please specify the name of your school or community site where you would like to enroll.

Grade*

Date of Birth*

Home Address*

Street Address Address Line 2 City State ZIP Code

Girl's Email Address

Girl's Phone Number

Ethnicity*

Parent/Guardian Information

Parent/Guardian Name 1*

First Last

Relationship*

Parent/Guardian Email Address*

Parent/Guardian Phone Number

Parent/Guardian Name 2

First Last

Relationship 2

Parent/Guardian Email Address 2

Parent/Guardian Phone Number 2

Applicant Lives With:*

Annual Household Income*

Household Size

Please indicate the number of individuals who reside in the household.

Does your family receive any type of governmental assistance? (i.e., WIC, food stamps, housing assistance, etc.)*

If yes, please list any types of assistance:

Additional Support: Is your daughter involved in one or more of the following:

Mental Health Services
School System (IEP/504 Plan)
Juvenile Justice System
Child Welfare System (i.e., DCS, CPS, etc.)
Other Youth Serving Organization

Medical Information

This information will be used in the event of an emergency.

Does your daughter have health insurance?*

Please specify the provider's name (i.e., BlueCross BlueShield, Tenncare, Humana, etc.)

Asthma?*

Yes
No

Does your child use an inhaler?*

Allergies?*

Yes
No

Physical Restrictions?*

Yes
No

If you marked "Yes" to any of the above medical conditions, please specify and elaborate below:

Any past trauma? If so, please elaborate.

Emergency Contacts

Please designate two (2) people we can contact if there is no answer when we attempt to reach you. These contacts MUST BE LOCAL.

Name: Emergency Contact #1

First Last

Relationship to Youth*

Cell Phone Number

Name: Emergency Contact #2

First Last

Relationship to Youth*

Cell Phone Number

Photo Release*

I agree.

I grant unrestricted permission for my child's image to be used in print, video and digital media. I agree that these images may be used by Girl Talk, Inc. for a variety of purposes and that these images may be used without further notifying me. I do understand that my child's last name will never be used in conjunction with any photo, video or digital images.

Medical/Emergency Contact*

I agree.

In the event of injury, or should emergency care be required and I nor my emergency contacts can be reached, I grant Girl Talk, Inc. staff, volunteers and/or mentors permission to authorize emergency medical attention for my child.

Field Trips/Signature Events*

I agree.

I understand that participation in Girl Talk includes participation in any and all activities, field trips, or events. I also understand that all reasonable safety precautions will be taken at all times by Girl Talk, Inc. and its agents during the activity. I hereby grant permission for my child to travel off-campus for field trips with Girl Talk staff or volunteers.

Liability Clause*

I agree.

I hereby indemnify and hold harmless Girl Talk, Inc. and its employees, agents, representatives and volunteers from any claims, damages, actions or causes of action arising or resulting from any bodily injuries, the effects thereof, or losses and damages arising therefrom, incurred or suffered by my child while in a facility or engaged in any organization sponsored activity, unless such loss or injury results directly from the gross negligence or willful act of any of the organization's employees acting within the scope of their employment or any of the organization's agents, representatives or volunteers.

Grade Release

At Girl Talk, Inc. we are training our girls to become successful women in today's society and we focus on ensuring academic achievement. I hereby agree to release a copy of my child's report card to Girl Talk staff and/or volunteers at the end of each 9 week grading period.

By typing my name below, I verify that this completed application is factual and completed to the best of my ability. I understand that participation is contingent upon acknowledging receipt of Girl Talk, Inc.'s policies and procedures.

First Last

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Girl Talk Girl School & Site-Based Application

Participant Information

Parent/Guardian Information

Medical Information

Emergency Contacts

Grade Release