Name: STEM %26 Literacy Camp
Start: 2022-06-13
End: 2022-07-01

Please fill out the form completely.

Participant Information

Participant's Name*

First Last

Participant's Date of Birth*

Participant’s Gender*

Male
Female
Other

Participant's School in Fall 2022*

Participant's Grade Level in Fall 2022*

Home Address*

Street Address Address Line 2 City State ZIP Code

Have they participated in Girls Inc. Programming during 2021-2022?*

Yes
No

If 'Yes' Please specify location

Primary Language of Participant*

English
Spanish
French
Other

Household Type*

NOTE: The data collected in the following questions are for official agency reports.

Family Income*

Participant's Ethnicity*

Latina/Hispanic/Latin American
Not Hispanic/Latina/Latin American

Participant's Race*

Asian American/Pacific Islander
Black/African American
Hispanic/Latina/Latin American
Native American/American Indian
White/Caucasian
Multiracial/Mixed Heritage
Prefer Not to Answer
Other

Please Select a T-Shirt Size*

List any allergies or dietary restrictions

Parent/Legal Guardian Information

Parent/Guardian Name*

First Last

Parent/Guardian Email Address*

Parent/Guardian Phone Number*

Parent/Guardian Name (2nd option)

First Last

Parent/Guardian Phone Number (2nd option)

Address*

Street Address Address Line 2 City State ZIP Code

Emergency Contact Information

Who should be contacted in the event of an emergency if a legal parent/guardian cannot be reached?

Emergency Contact #1 Name*

First Last

Emergency Contact #1 Phone Number*

Emergency Contact #1 Relationship*

Emergency Contact #2 Name

First Last

Emergency Contact #2 Phone Number

Emergency Contact #2 Relationship

These people have permission to pick up my child from camp.

Please add names and phone numbers.

Program Information

How did you hear about our in person camp?*

Media Release
Girls Inc. of Tarrant County will use photographs of the children in agency publications such as brochures, website, and flyers. Your child’s photographs will not be used or sold to any other agencies. If you do not want your child’s photo to be used, please submit a signed letter stating your denial of permission.

Review and check the following boxes.*

My child may participate in all camp activities.
My child has permission to be transported to/from field trips.
My child may be photographed.
Parent/guardians and emergency contacts have permission to pick up my child from camp.

As a legal guardian, I give permission for the registrant to participate in all camp activities and off-site trips. In an emergency, when the undersigned or emergency contact cannot be reached, I give permission for camp authorities to take any emergency measures deemed appropriate. It is understood that all reasonable efforts will be made to contact the parent/guardian. I further agree to indemnify, protect, and hold harmless Girls Inc. of Tarrant County or other organizations volunteering services without charge to supervise participating children from claim or liability, including but not limited to: personal injury, property damage, court costs, attorney's fees and interest as a result of my child's participation. I further agree that Girls Inc. of Tarrant County reserves the right to terminate the participation of my child in the program for failure to behave in accordance with regulations on conduct, or for failure to follow the instructions of supervisors deemed to be detrimental to the interest, comfort, or welfare of the program. If participation is terminated, fees will not be reimbursed.*

By checking here, I (parent/legal guardian) agree to the terms above. This check serves as the electronic signature of the parent/guardian.

For additional information, please call Karina Diaz at (817) 259–1050 or email [email protected]

Date

Time

STEM & Literacy Camp