Girls Inc. Online Application Please fill out the form completely.Student InformationName* First Last Date of Birth* Date Format: MM slash DD slash YYYY Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code School Attending*Grade*Primary Language of Student* English Spanish French Other Have you been in Girls Inc. before?* Yes No If yes, what location?Parent/Guardian InformationGuardian #1 Name* First Last Guardian #1 Phone*Guardian #1 Email* Guardian #2 Name First Last Guardian #2 PhoneGuardian #2 Email Household Type*Father OnlyMother OnlyTwo ParentsOne Parent at a Time (Joint Custody)OtherUnknown/UnavailableFamily Income*Less than $10,000$10,000 – $20,000$20,001 – $30,000$30,001 – $50,000Greater than $50,000Unknown/UnavailableRace* Asian American/Pacific Islander Black/African American Hispanic/Latina/Latin American Middle Eastern/North African Native American/American Indian White/Caucasian Multiracial/Mixed Heritage Unknown/Unavailable Ethnicity* Latina/Hispanic/Latin American Not Hispanic/Latina/Latin American Missing/Refused/Unknown Emergency Contact InformationWho should be contacted in the event of an emergency if a legal parent/guardian cannot be reached? Name* First Last Phone*Relationship*Military*YesNoIs anyone in your family an active member of the military? If so, Who? (Ex. Mom, Dad, Cousin, etc.)If yes, who?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.Would you like to receive more information regarding Girls Inc. programs and events?*YesNoEmail Consent to Transport I give permission for my child to be transported by Girls Inc. of Tarrant County. I understand that Girls Inc. of Tarrant County will transport my child to and from the location. I release Girls Inc. of Tarrant County from all liability for any adverse results that may occur. I agree to release Girls Inc. of Tarrant County and its employees and officers from all liability with reference to the above-stated transportation.* By checking here, it will serve as the electronic signature of the parent/guardian. For additional information, please call Karina Diaz at (817) 259–1050 or email [email protected]
