Parent/Guardian Contact Information

*Please fill out one form per child

Country*
State / Province*
Address*
City*
*
*
*
*
*
*
Email*
Confirm Email*
Phone*
Child's First Name
Child's Last Name
Child's Birth Date (dd/mm/yyyy)
Child's School
Relationship to Child
Alternate/Emergency Contact Name
Alternate/Emergency Contact Phone Number
Second Alternate/Emergency Contact Phone Number
Media Release: There may be occasions where pictures of your daughter will be taken - these photos will be used for newsletting, videos, brochures, annual reports, radio, television, newspapers and our website*
  • I give my permission for my daughter to appear in any Girls Inc. of Durham publications
  • I do NOT give permission for my daughter and/or myself to appear in any Girls Inc. of Durham publications
Please list any medical or allergen information you would like us to be aware of.
How did you hear about this program?

Membership Information

To purchase a membership to save 20% off ALL Girls Inc. Programming for one year, please click here

 

If you do not wish to purchase a membership, please scroll down to the "Non-Member" section.

 

If your membership is still active for the year, please select from the "Member" section.

GirlZONE Registration

Quantity
Price
Total
September: Member
X
$
25.00=
$
0

September: Non-Member
X
$
40.00=
$
0

November: Member
X
$
25.00=
$
0

November: Non-Member
X
$
40.00=
$
0

February: Member
X
$
25.00=
$
0

February: Non-Member
X
$
40.00=
$
0

April: Member
X
$
25.00=
$
0

April: Non-Member
X
$
40.00=
$
0

June: Member
X
$
25.00=
$
0

June: Non-Member
X
$
40.00=
$
0

Final Total:
$
0

Payment Information

Amount*
$
Name on Card*
Card Number*
Additional Comments

Security Code