Girl’s With Voices (GWV)Registration Form Childs Information * First Name Last Name Phone (###) ### #### Date of Birth Age Childs Race/Ethnicity African American/Black Hispanic/Latino Caucasian/White Asian/Pacific Multi-Racial Grade School Home Address City State Zip Code Parent/Guardian Info * Name Relationship Home/Cell Emergency Contact Name Relationship Home/Cell Other than Parent/Guardian, is anyone else authorized to pick up your child? Yes No If so, please state the person's name I give permission for my child to be photographed for program/promotional purposes Yes No There is no transportation to and from the program. Will you be able to pick up your child upon dismissal? Yes No I give my child permission to walk to program Yes No I give my child permission to walk from program Yes No I give my child permission to participate in counseling sessions with a licensed therapist for group discussion Yes No Parent/Guardian Signature Date Thank you!
