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
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
Please list any medical or allergen information you would like us to be aware of.

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.

Whitby March Break Camp Registration

Quantity
Price
Total
Member
X
$
140.00=
$
0

Non-Member
X
$
165.00=
$
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

Security Code