Parent(s)/Guardian(s)

This segment is to be completed by the parent(s)/guardian(s).
* = required

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* 1. Girl's Full Name

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* 2. Girl's Date of Birth

Date

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* 3. Primary Parent/Guardian's Full Name

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* 4. Relationship to Girl/Applicant:

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* 5. Home Address

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* 6. Parent/Guardian Contact Info

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* 7. Tshirt Size

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* 9. Will girl have a relative in camp?

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* 10. If yes to the question above, name of relative in camp: 

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* 11. Has daughter participated in Girls Inc. Program(s)?
(Select all that apply)

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* 12. If yes to the question above, list programming site names:

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* 13. Choose the camp that your daughter will attend (choose one):

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* 14. Please choose one mandatory parent orientation to attend: 

For Parents/Guardians and Girls together, please read and sign below:

We understand the commitment required for the Concordia summer camp. If we are selected to join the program, we agree that our participant will attend every day, Monday-Friday, during the 4-week period from June 29th-July 17th. I also understand that she may only be absent twice during the 4 week camp.

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* 15. I understand that:

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* 16. Electronic Signature

Questions? Please contact Virgtrese, Program Manager

510-357-5515 ext. 257

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