Parent/Guardian Contact Information

*Please fill out one form per child

Relationship to Child
How did you hear about this program?
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
Alternate/Emergency Contact Name
Alternate/Emergency Contact Phone Number
Second Alternate/Emergency Contact Phone Number
Please list any medical or allergen information you would like us to be aware of.
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 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

Program Permission

I herby grant permission for my child to participate in Girls Inc. of Durham Camp 2018 program. I give my consent for her to participate in field trips and neighbourhood outings arranged by the staff at Girls Inc.of Durham. Parents will be notified in advance of any such trips and may be asked to provide additional support depending on the outing.

 

I understand that my daughter may be transported by vehicle or walking, with adult supervision, in order to arrive at the destination. I understand that my medical coverage is the primary insurer for my child and will not hold Girls Incorporated of Durham responsible in case of an accident or injury.

Program Permission*
  • Yes
  • No

Sunscreen Application Permission

As the parent/guardian of  the  above  child, I  recognize  that  too  much  exposure  to  UV  rays  may  increase  my  child’s  risk  of  getting  skin  cancer  someday.  Therefore,  I  give  permission  for  the  staff  at;  Girls  Inc.Summer  Camp  to  apply  a  sunscreen  product  (provide  by  the  family)  thatis  broad  spectrum  with  SPF  15  or  higher  to  my  child.    Girls  Inc.will  make  every  effort  to  limitthe  amount  of  time  spent  outside  betweenthe  daily  time  of  11  a.m.  and  2  p.m.  I  understand  that  sunscreen  may  be  applied  to  exposed  skin,  including  but  not  limited  to  the  face  (except  eyelids),  tops  of  ears,  nose,  bare  shoulders,  arms  and  legs. I have  checked  and  initialed  below  all  applicable  information  regarding  Girls  Inc.  applying  sunscreen. 

Sunscreen Application Permission*
  • Yes
  • No

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.

Quantity
Price
Total
Member
X
$
145.00=
$
0

Non-Member
X
$
170.00=
$
0

Before and After Care Member (8:30am-9:00am and 4:00pm-4:30pm)
X
$
40.00=
$
0

Before and After Care Non-Member (8:30am-9:00am and 4:00pm-4:30pm)
X
$
50.00=
$
0

Final Total:
$
0
Would you like to sign up for the CIT Program? (March Break Camp Counsellors in Training, 13-16yrs)
  • Yes
  • No

Payment Information

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

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