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The Girl Talk Youth Advisory Board
School & Site-Based
The Girl Talk LIFE Prep Academy
Upcoming Program Events
Be a Girl Talk Girl
Enroll in the Girl Talk LIFE Prep Academy
Be a Girl Talk 1:1 Mentor
Be a Girl Talk School & Site-Based Mentor
Be a Girl Talk Life Prep Academy Volunteer or Career Coach
Desire to Inspire
Fashion Show Gala
Enroll in the Girl Talk School & Site-Based Program!
Girl Talk Girl School & Site-Based Application
Date of Application
MM slash DD slash YYYY
Girl's Full Name
Name of School or Site
Please specify the name of your school or community site where you would like to enroll.
Date of Birth
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Girl's Email Address
Girl's Phone Number
Parent/Guardian Name 1
Parent/Guardian Email Address
Parent/Guardian Phone Number
Parent/Guardian Name 2
Parent/Guardian Email Address 2
Parent/Guardian Phone Number 2
Applicant Lives With:
Annual Household Income
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
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.)
Does your child use an inhaler?
If you marked "Yes" to any of the above medical conditions, please specify and elaborate below:
Any past trauma? If so, please elaborate.
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
Relationship to Youth
Cell Phone Number
Name: Emergency Contact #2
Relationship to Youth
Cell Phone Number
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.
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 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.
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.
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.
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