2024-25 Girls Inc. of Alameda County: School Based Enrollment Form

1. What type of program is your participant(s) enrolling in? *This question is required.

2. How many participants are you enrolling? You will have to enter participant specific information for each (i.e. birthdate, school site, allergy information, etc.) *This question is required. This question requires a valid number format.

3. Today's Date: (MM/DD/YYYY) *This question is required. This question requires a valid date format of MM/DD/YYYY.

calendar

4. Name of Person Completing this Form: *This question is required.

5. Relationship to Participant(s) (if "Other", please specify) *This question is required.

Guardian Information

6. Primary Guardian First Name *This question is required.

7. Primary Guardian Last Name *This question is required.

8. Relationship to Participant (if "Other", please specify) *This question is required.

9. Phone Number *This question is required.

10. Do you consent to receive phone calls and text messages from Girls Inc. at the number provided? *This question is required.

11. Email Address *This question is required.

12. Address: *This question is required.

Space Cell	Address Information
Street Address	Street Address: Address Information
Apartment	Apartment: Address Information
City	City: Address Information
State	State: Address Information
Zip Code	Zip Code: Address Information

13. This is the participant(s)': *This question is required.

14. Total Number of People Living in Household (Including yourself): *This question is required. This question requires a valid number format.

15. Annual Household Income: *This question is required.

16. Primary Language Spoken at Home (If "Other" please specify): *This question is required.

16. Primary Parent/Guardian Highest Level of Education (If "Other" please specify): *This question is required.

16. Would you like to enter another Primary Guardian? *This question is required.

17. Second Primary Guardian First Name

17. Second Primary Guardian Last Name

17. Relationship to Participant (if "Other", please specify)

17. Phone Number

17. Email

17. Address:

Space Cell	Address Information
Street Address	Street Address: Address Information
Apartment	Apartment: Address Information
City	City: Address Information
State	State: Address Information
Zip Code	Zip Code: Address Information

17. This is the participant(s)':

Emergency Contact Information

List below any emergency contacts. This person is authorized to pick up your child in the case of an emergency. This person must be at least 18 years old.

17. Primary Emergency Contact First Name: *This question is required.

18. Primary Emergency Contact Last Name: *This question is required.

19. Relationship to Participant (if "Other", please specify) *This question is required.

19. Phone Number *This question is required.

20. Email *This question is required.

21. Address: *This question is required.

Space Cell	Address Information
Street Address	Street Address: Address Information
Apartment	Apartment: Address Information
City	City: Address Information
State	State: Address Information
Zip Code	Zip Code: Address Information

22. Would you like to add information for another Emergency Contact? *This question is required.

23. Secondary Emergency Contact First Name:

23. Secondary Emergency Contact Last Name:

23. Relationship to Participant (if "Other", please specify)

23. Phone Number

23. Email

23. Address:

Space Cell	Address Information
Street Address	Street Address: Address Information
Apartment	Apartment: Address Information
City	City: Address Information
State	State: Address Information
Zip Code	Zip Code: Address Information

2024-25 Girls Inc. of Alameda County: School Based Enrollment Form

2024-25 GIAC Enrollment Form