BECOME A STRONG,SMART AND BOLD GIRL

Child's Name (required)

Address (required)

Best Contact Phone Number (required)

Age (required)

Birthdate (required)

Grade (required)

School

SSN (required)

Physician's Name

Physician's Phone Number

Preferred Hospital

Medical/ Physical Information.please list any disabilities the child has

Race/Ethnicity Profile
African AmericanHispanicNative AmericanWhite/AngloAsian AmericanPacific IslanderMultiracialOther

Primary Guardian's Relationship to Child
MotherFatherOther Guardian

Primary Guardian's Name

Primary Guardian's Address

Primary Guardian's Employer

Primary Guardian's Employer Phone Number

Primary Guardian's Email Address (required)

Primary Guardian's Race/ Ethnicity Profile
African AmericanHispanicNative AmericanWhite/AngloAsian AmericanPacific IslanderMultiracialOther

Secondary Guardian's Relationship to Child
MotherFatherOther Guardian

Secondary Guardian's Name

Secondary Guardian's Address

Secondary Guardian's Employer

Secondary Guardian's Employer Phone Number

Secondary Guardian's Email Address

Secondary Guardian's Race/ Ethnicity Profile
African AmericanHispanicNative AmericanWhite/AngloAsian AmericanMultiracialPacific IslanderOther

Additional Emergency Contact

Additional Emergency Contact Phone

Additional Emergency Contact Relationship to Child

Household Income
$10,000 or less$10,000 - $20,000$20,000 - $30,000$30,000 - $50,000$50,000 +

Primary Language Spoken in Home
EnglishSpanishVietnameseOther

Are Parents Separated?
YesNo

If yes, who does the child live with?
MotherFatherJoint CustodyOther

Media Release, Medical Waiver, Program Release and Transportation Release: "I hereby give Girls Inc. of Fort Smith and participating agencies permission to use film, video tape, and/or photographs of the above mentioned minor for lawful promotional or informational purposes which may include, but is not limited to, an e-newsletter and social media sites. In case of a medical or surgical emergency, after every reasonable effort has been made to contact the parent or legal guardian, I hereby give my permission to medical personnel selected by Girls Inc. staff, volunteers or other associated adults to provide whatever emergency or surgical treatment is necessary for the above referred child. I hereby give permission for the above referred child to participate in local National Girls Inc. programs that may include pre and post surveys and other statistical data collection for reporting purposes. *Parents will always be informed of participation in a national program with specific schedules and descriptions.* I hereby give permission for the above referred child to travel on a Girls Inc. van or bus for field trips and other activities she signs up for that may require transporting. I understand that she will be required to sign up for field trips offered but is not guaranteed a spot every time because spaces are limited. I also understand that membership fees are non-refundable."

Electronic Signature