Contact Information

Country
State / Province*
Address
City
Email*
Confirm Email*
Phone
Child's First Name
Child's Last Name
Child's Birth Date (dd/mm/yyyy)
Current School
Please list any dietary accomodations you require
Media Release: There may be occasions where pictures of your daughter will be taken - these photos will be used for newsletters, videos, brochures, annual reports, radio, television, newspapers and our website*
  • I give permission for my daughter and/or myself 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
Registration Date - Please select one or more option(s)
  • July 21: Physical Activity
How did you hear about this program?
Additional Comments

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