Summer 2021 – Enrollment – Girls Inc of Sioux City

PARENT/GUARDIAN INFORMATION
Mother's Info
Mother's First Name Mother's Last Name Mother's Employer Mother's Cell Phone Mother's Work Phone
Mother's Address
Mother's Address City State Zip Code
Father's Info
Father's First Name Father's Last Name Father's Employer Father's Cell Phone Father's Work Phone
Father's Address
Father's Address City State Zip Code
Guardian Info
Guardian First Name Guardian Last Name Guardian Employer Guardian Cell Phone Guardian Work Phone
Guardian Address
Guardian's Address City State Zip Code
EMERGENCY CONTACTS
Must have two emergency contacts who do NOT reside in the same household.
Emergency Contact 1*
First Name Last Name Cell Phone Work Phone
Emergency Contact 2*
First Name Last Name Cell Phone Work Phone
MAY NOT PICK UP
No Pick Up
Is there a court order that restricts anyone from contact with your child/children? (It is the parent/guardian’s responsibility to provide documentation.)
- Yes
- No
No Pick Up Explanation
If yes, please list and explain:

SELECT SESSIONS
Sessions Selected*
Session One: June 1- July 2
Session Two: July 12-August 13
CHILD ENROLLING
She must be 6 or turn 6 within 30 days of start of session.
Child's Name
Child's First Name Child's Last Name
Child's Details
Age Date of Birth School Grade Fall '21
T-shirt Size
Ethnic/Racial Heritage
Ethnic/racial information is for statistical purposes only for grants and other funders. The information is confidential and will not be shared with any identifying information. Select two or more for multiracial.
- American Indian/Alaska Native
- Asian
- Black/African American
- Hispanic/Latino
- Pacific Islander
- White
Languages Spoken at Home
Indicate all that apply.
- English
- Spanish
- Other:
Other Languages
Child Lives With:
Please check all that apply.
- Mother
- Father
- Legal Guardian
- Other:
Child Address
Address where child lives IF DIFFERENT from Parent(s) or Guardian.
Street Address City State Zip Code
My Child Has a Social Worker
- Yes
- No
Social Worker Details
First Name Last Name Cell/Work Phone
Social worker meeting at GI
Will her social worker be meeting with her at Girls Inc.?
- Yes, will be meeting with her at Girls Inc.

SELECT SESSIONS
Sessions Selected 2
Session One: June 1- July 2
Session Two: July 12-August 13
CHILD ENROLLING
Must be 6 or turn 6 within 30 days of start of session.
2nd Child's Name
Child's First Name Child's Last Name
2nd Child's Details
Age Date of Birth School Grade Fall '21
T-shirt Size
Ethnic/Racial Heritage
Ethnic/racial information is for statistical purposes only for grants and other funders. The information is confidential and will not be shared with any identifying information. Select two or more for multiracial.
- American Indian/Alaska Native
- Asian
- Black/African American
- Hispanic/Latino
- Pacific Islander
- White
Child Lives With:
Please check all that apply.
- Mother
- Father
- Legal Guardian
- Other:
Child Address
Address where child lives IF DIFFERENT from Parent or Guardian.
Street Address City State Zip Code
My Child Has a Social Worker
- Yes
- No
Social Worker Details
First Name Last Name Cell/Work Phone
Social worker meeting at GI
Will her social worker be meeting with her at Girls Inc.?
- Yes, will be meeting with her at Girls Inc.

SELECT SESSIONS
Sessions Selected 3
Session One: June 1- July 2
Session Two: July 12-August 13
CHILD ENROLLING
Must be 6 or turn 6 within 30 days of start of session.
3rd Child's Name
Child's First Name Child's Last Name
3rd Child's Details
Age Date of Birth School Grade Fall '21
T-shirt Size
Ethnic/Racial Heritage
Ethnic/racial information is for statistical purposes only for grants and other funders. The information is confidential and will not be shared with any identifying information. Select two or more for multiracial.
- American Indian/Alaska Native
- Asian
- Black/African American
- Hispanic/Latino
- Pacific Islander
- White
Child Lives With:
Please check all that apply.
- Mother
- Father
- Legal Guardian
- Other:
3rd Child Address
Address where child lives if different from Parent or Guardian.
Street Address City State Zip Code
My Child Has a Social Worker
- Yes
- No
Social Worker Details
First Name Last Name Cell/Work Phone
Social worker meeting at GI
Will her social worker be meeting with her at Girls Inc.?
- Yes, will be meeting with her at Girls Inc.

SELECT SESSIONS
Sessions Selected 4
Session One: June 1- July 2
Session Two: July 12-August 13
CHILD ENROLLING
Must be 6 or turn 6 within 30 days of start of session.
4th Child's Name
Child's First Name Child's Last Name
4th Child's Details
Age Date of Birth School Grade Fall '21
T-shirt Size
Ethnic/Racial Heritage
Ethnic/racial information is for statistical purposes only for grants and other funders. The information is confidential and will not be shared with any identifying information. Select two or more for multiracial.
- American Indian/Alaska Native
- Asian
- Black/African American
- Hispanic/Latino
- Pacific Islander
- White
Child Lives With:
Please check all that apply.
- Mother
- Father
- Legal Guardian
- Other:
4th Child Address
Address where child lives if different from Parent or Guardian.
Street Address City State Zip Code
My Child Has a Social Worker
- Yes
- No
Social Worker Details
First Name Last Name Cell/Work Phone
Social worker meeting at GI
Will her social worker be meeting with her at Girls Inc.?
- Yes, will be meeting with her at Girls Inc.

ENROLLMENT CERTIFICATION
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/children must meet the age requirements and must be able to function appropriately in a group setting. I further understand that my child’s/children’s enrollment is not complete until I have submitted/completed all required forms and fees and her/their enrollment has been confirmed. I understand that all fees paid are nonrefundable and that I will be responsible for all fees associated with the sessions for which I enroll her/them.
*
I agree. Please accept this enrollment application.

Summer 2021 – Enrollment