Application Form

  
Are You a New or Returning Participant New Student
Which Location Are you Applying For  
First Name
Last Name
Home Address
City
State
Zipcode
Phone Number
Date Of Birth
Email Address
Ethnicity
Parent or Guardian Name
Parent or Guardian Address
City/ State / Zipcode
Parent or Guardian Work Number
Cell Phone
Email Address

EMERGENCY CONTACT

 
1.) Name/ Relationship / Phone
2.) Name/ Relationship / Phone
Please List Person(s) Names allowed to pick up Participant Name
  Name
Please List any Medical or Physical Conditions
Please List any Allergies
Education Information  
School
Address
City/State/Zipcode
Phone
Extra Curricular Activities
GRADES
 
What Was The Last Grade You Received in Math
What Was The Last Grade You Received in Science
What is your Current GPA
What is Your Favorite Subject

RELEASE AUTHORIZATIONS

 
PHOTOGRAPH CONSENT AND WAIVER: I understand that Girls 4 Science may photograph my child individually or in group settings. I understand that photos may be used in brochures, web site, newspapers, presentations, and television spots to further publicize the mission of the organization. I give full consent for these and similar uses of my child's photographic likeness, waiving any liability for Girls 4 Science or its directors or employees

Legal Parent/Guardian Signature

EMERGENCY MEDICAL AUTHORIZATION: I understand that in the event of accident or illness, every effort will be made to contact parent/guardian immediately. If parent/guardian cannot be reached, I authorize Girls 4 Science to obtain emergency care for my child

Legal Parent/Guardian Signature

FIELD TRIP PERMISSION I/We do hereby agree to release and hold harmless Girls 4 Science its officers, Board of Directors, volunteers and employees from any and all claims, costs, suits, actions, judgments, and expenses for any damage, loss, or injury to my/our child or damage to my/our child's property arising from my/our child's participation in field trips.

I/We (Parent/Guardian), of

(Child),give permission for my/our Child to attend Girls 4 Science field trips.

Electronic Signature
 PHP Form by FormToEmail.com