Afterschool Enrollment – Girls Inc of Sioux City

Afterschool Enrollment Form

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CHILD'S INFORMATION

Child's First Name*

Child's Last Name*

Date of Birth*

MM slash DD slash YYYY

Age*

School*

Grade 2025-26*

What grade will your child be in this school year?

Ethnic/Racial Heritage*

American Indian/Native Alaskan

Asian

Black/African American

Hispanic/Latino

Pacific Islander

White

(Please select 2 or more for multiracial.)

Language(s) Spoken at Home*

English

Spanish

Other (list below)

(Please select/list all languages spoken.)

Other Language(s) spoken at home.

Child's Home Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Child Lives With (check ALL that apply)*

Both Mother and Father

Shared Custody Mother and Father

Mother Only

Father Only

Grandparent(s)

Legal Guardian(s)

Other (explain below)

Child Lives With Other Details

CHILD'S HEALTH DETAILS

Please provide as detailed information as possible so that we may best meet her needs while at Girls Inc.

Allergies or Restrictions?*

Yes

Please explain any allergies or restrictions (including food allergies):

Operations or Illnesses?*

Yes

Details of any operations or illnesses:

Behavioral/Emotional/Trauma Issues?*

Yes

Details of any behavioral, emotional, or trauma issues:

Regular Medications?*

Yes

Please list ALL medications your child is taking, even if not given at Girls Inc.:

Will Girls Inc. be administering any medication(s)?*

Yes

Please describe which medications Girls Inc. will administer, when, how much, etc.

May we give your child Tylenol if necessary?*

Yes

Does your child have an IEP (Individualized education program)?*

Yes

If yes, please submit a copy of the IEP.

Child's Doctor/Pediatrician*

Doctor's Office Phone*

Child's Dentist*

Dentist's Office Phone*

CHILD'S CONCERNS/BEHAVIOR/HISTORY

Please select ALL that apply.

Please select ALL that apply to your child.*

Overweight/fitness

underweight/won't eat

body image

nutrition/eating disorder

stress/anxiety/worry

making/keeping friends

perfectionism

shyness/withdrawn

struggles in school

reading/writing

attention/focus issues

ADD/ADHD (diagnosed)

anger issues

bullies/is bullied

past sexual abuse

trauma (explain below)

parent in prison

foster care/shelter

homeless past/current

hygiene

none of the above

Please explain or add details for anything selected above:

My child has a social worker.*

Yes

Social Worker First Name

Social Worker Last Name

Social Worker Phone Number

PARENT/GUARDIAN INFORMATION

MOTHER

First Last

Mother's Cell Phone

Mother's Employer

Mother's Work Phone

Mother's Email

Is Mother's address DIFFERENT than child's home address?*

Yes

Mother's Address (only if different from child)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

FATHER

First Last

Father's Cell Phone

Father's Employer

Father's Work Phone

Father's Email

Is Father's address DIFFERENT from child's address?

Yes

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

GUARDIAN

First Last

Guardian's Cell Phone

Guardian's Employer

Guardian's Work Phone

Guardian's Email

EMERGENCY CONTACTS

Please list TWO adults to be contacted in an emergency or for child pick up in case the parent(s) or guardian cannot be reached. List only those who have your permission to pick up your child if needed.

First Name*

Last Name*

Cell Phone*

Work Phone

First Name*

Last Name*

Cell Phone*

Work Phone

Is there anyone who MAY NOT pick up your child?*

Yes

May NOT Pick Up - List name(s) and explain:

(It is the parent's/guardian's responsibility to provide any documentation if needed.)

PARENT AND GIRL POLICIES AND RESPONSBILITIES

Please read carefully through each of the following policies and check the acknowledgement at the bottom when finished.

Afterschool until 7:00pm. Pick-up begins at 5:00pm. Dinner is served at 5:20pm. Extended programming and clubs continue until 6:45.

PROGRAM HOURS

Afterschool until 7:00pm. Pick-up begins at 5:00pm. Dinner is served at 5:20pm. Extended programming and clubs continue until 6:45.

Girls Inc. has transportation from school to Girls Inc. available from a limited number of schools. Transportation is not guaranteed.

TRANSPORTATION

Girls Inc. has transportation from school to Girls Inc. available from a limited number of schools. Transportation is not guaranteed.

Girls are not dismissed until 5:00pm. We ask that girls are picked up by 5:20 if they will not be staying for dinner. All girls must be picked up by 7:00pm. Girls are not dismissed until after 5:00pm, but must be picked up by 7:00pm for the Extended program. (Note: dinner is served at 5:30pm.)

PICK UP

All girls must be picked up by 7:00pm. A late fee of $10 per child will be charged for the first 5 minutes and $1 for every minute after that. The Sioux City Police Department will be contacted if parents are more than 30 minutes late. More than two late pickups may result in suspension from the program without refund.

LATE POLICY

Girls Inc. is an intentional development program for girls and regular attendance is critical to your child getting the most from the program. Excessive absences may result in dismissal from the program, without refund of any kind.

ATTENDANCE

All girls must be able to function in a group setting and abide by Girls Inc. rules. This includes behavior on the bus and vans, at the center, or at events with Girls Inc. If your child is not able to behave in a group setting or requires one-on-one assistance from staff, you will be notified and your child will need to be picked up. Should your child have recurring problems abiding by these rules, she may be dismissed from the program without refund.

BEHAVIOR

At Girls Inc. we strive to treat all staff, girls, and parents with respect and courtesy at all times, including using appropriate language, respecting property and equipment and not using verbal or physical aggression towards another person. Should you or your child have recurring problems abiding by these rules, she may be dismissed from the program without refund.

RESPECT

Do NOT send your child if she is ill or has any contagious conditions such as pink eye, head lice, strep, etc. Girls Inc. conducts intermittent lice checks and your child will be sent home if nits or bugs are present. When you treat your child, and lice/nits are removed, she will be allowed to come back. She will be checked upon her return.

GENERAL HEALTH

Girls Inc. of Sioux City follows the guidance of the CDC and other health experts. Any girl exhibiting common symptoms of COVID-19 while at Girls Inc. will be isolated and parents notified. Parents/guardians MUST pick up their child within 30 minutes of notification. Parents/guardians MUST immediately notify Girls Inc. if they discover that their child has been exposed to someone diagnosed with COVID-19. In both case, she will not be allowed to return until the standard recovery time has expired or until proof of a negative COVID-19 test is provided.

COVID-19

Girls Inc. provides all girls with an afternoon snack each day. A nutritious dinner is provided at 5:20pm for all girls still in attendance. If your child has special dietary needs, please let us know in advance and we will try to accommodate. (Medical professional documentation may be required.) Absolutely NO outside food, candy, or gum is allowed.

FOOD

Girls Inc. is often very active - comfortable clothing she typically wears to school is suitable, but as much as possible she should have closed toe shoes.

CLOTHING

Girls Inc. is often very active - comfortable clothing she typically wears to school is suitable, but as much as possible she should have closed toe shoes.

Personal belongings should be kept to a minimum (backpacks and related items from school). Cell phones, jewelry, money, electronics, etc. should be left at home. Any such items brought to Girls Inc. will be held at the front desk until departure.

PERSONAL BELONGINGS

Girls are not allowed to use the phone in the center. If a parent needs to get in touch with a child, a staff member will take the call and relay a message to her. Personal cell phones are not allowed.

PHONE CALLS

At least one parent/guardian must sign up for Class DoJo, which is the free app used for important communication with parents.

CLASS DOJO

At least one parent/guardian must sign up for Class DoJo, which is the free app used for important communication with parents.

Field trips are an occasional part of Girl Inc.'s program. Girls may participate in walking or transported field trips. Girls may NOT be picked up at a field trip location. Parents will be notified if an activity will keep girls past their normal pickup time.

FIELD TRIPS

We only share information about your child with the staff working directly with her. To ensure your child has the safest, most productive, and fun experience, we ask that you be honest when reporting all information about your child so staff is able to design and modify programming and other activities to best suit her individual needs.

CONFIDENTIALITY

Comprehensive sex education is delivered to ages 12 and up.

SEX EDUCATION

Comprehensive sex education is delivered to ages 12 and up.

Dues are invoiced in the first week of the month or each week, depending on which payment plan you opted for. Invoices are due upon receipt. Past due fees may not exceed two weeks, or your child may be dismissed from the program without refund. If there is a problem paying, please speak with the Program Director rather than risk dismissal.

DUES AND PAYMENT

Absolutely NO refunds may be given under any circumstances for any fees paid. Additionally, you will be held responsible for any unpaid fees for weeks for which you have registered.

NO REFUNDS

Absolutely NO refunds may be given under any circumstances for any fees paid. Additionally, you will be held responsible for any unpaid fees for weeks for which you have registered.

Parental support and involvement are vital for your child to get the most out of Girls Inc. Our goal is to work together to help her have an enjoyable and successful experience Girls Inc. Keeping up with your child on Class Dojo is essential.

PARENT/GUARDIAN SUPPORT

ACKNOWLEDGEMENT*

I have carefully read and fully understand these policies and responsibilities. By checking here and submitting this form, I agree to abide by these policies and understand that failure to abide by these policies will result in my child being dismissed from Girls Inc.. I further acknowledge that any fee paid is nonrefundable.

RELEASE/CONSENT/WAIVER

Emergency Medical Release and Consent*

I have read and hereby agree to the Emergency Medical Consent below.

In the event that I am unable to be reached and my child requires medical, dental or surgical treatment while in the care of Girls Inc. of Sioux City, I hereby grant permission to the hospital, doctor, dentist or their designees to administer such medical, dental or surgical care/treatment as may be appropriate or deemed necessary. I agree to pay all costs and fees resulting from any such emergency medical, dental, or surgical care/treatment for my child as secured or authorized under this consent. This consent shall remain in effect from the date submitted until such time as my child is no longer enrolled with Girls Inc. of Sioux City.

Media Release*

I agree to the media consent, release and waiver policy below.

I hereby give consent to Girls Inc. of Sioux City to photograph, videotape, or otherwise digitally record and use images and/or sound recordings of my child or children to use in any public media, including radio, television, internet, social media, print or in any of Girls Inc.’s or its partners’ publications, productions, or posts. I understand the intended use of such images and information is solely for the purpose of advertising, marketing, fundraising and/or the promotional and public awareness purposes for Girls Inc. and that identifying informing information will be limited to first names (if at all). I hereby waive any rights or interest in such images or recordings and forever discharge Girls Inc. (including without limitation all corporate affiliates and officers, directors, trustees, donors, employees, agents and volunteers) from any and all claims, liability, actions, suits, demands, costs, expenses or indebtedness arising out of, related to, or in any way connected with the use of images and materials described herein, and I hereby waive all rights and interest in and to such information and materials.

Enrollment Certification*

By submitting this form and with my signature below, I certify that all of the information in this enrollment form is true and complete to the best of my knowledge. I understand that my child must meet the age requirements and must be able to function appropriately in a group setting. I further understand that my child’s enrollment is not guaranteed and is not complete until I have submitted/completed all required forms. I further acknowledge that all fees paid are nonrefundable and that I will be responsible for all fees associated until such time as I officially unenroll her from the program.

Signature*

FEE/BILLING INFORMATION

For your convenience and greater accuracy, Girls Inc. now bills electronically only. Invoices will be sent automatically to the e-mail address you provide below (at the start of the month or each week, depending on which plan you chose). While cash or check payments may be made in person at Girls Inc., paying through the secure link sent with your invoice is the best way to have your payment credited quickly and accurately. No credit card payments will be accepted at Girls Inc.

Preferred e-mail Address for Billing*

Please enter the e-mail address you would like invoices sent to for summer.

Billing e-mail Address*

Please re-enter the e-mail address you would like invoices to be sent to.

IOWA ELIGIBILITY APPLICATION

Girls Inc. is required to have current Iowa Eligibility Applications for each girl for its meal program. If you haven't already, you can download it from the Girls Inc. website or pick one up at Girls Inc. Enrollment in the Summer Program cannot be completed until this form is filled out and returned.