Summer Registration | Inspiring All Girls to be Strong, Smart & Bold

Summer 2025

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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 Fall 2025*

What grade will your child be starting in September?

T-shirt Size*

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:

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shyness/withdrawn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.

Summer Hours are Monday-Friday 7:30am to 5:30pm.

SUMMER HOURS

Summer Hours are Monday-Friday 7:30am to 5:30pm.

Girls Inc. does not provide transportation to or from Girls Inc. during the summer.

TRANSPORTATION

Girls Inc. does not provide transportation to or from Girls Inc. during the summer.

Your child should be dropped off no later than 9:00am each day.

DROP OFF BY 9:00

Your child should be dropped off no later than 9:00am each day.

Your child should NOT be picked up prior to 4:00pm, but must be picked up by 5:30pm.

PICK UP AFTER 4:00

Your child should NOT be picked up prior to 4:00pm, but must be picked up by 5:30pm.

All girls MUST be picked up by 5:30. 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 REQUIREMENT

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

Summer at Girls Inc. is very active - please send your child in comfortable clothing such as play clothes and shorts so that she may participate in all activities. She MUST have closed toe shoes (no flip flops). Remember to send her swimsuit on her age group's swimming day.

CLOTHING

Girls Inc. provides breakfast, a nutritious lunch, and an afternoon snack each day. If your child has special dietary needs, please let us know in advance and we will try to accommodate. (Medical professional documentation is required.) Absolutely NO outside food, candy, or gum is allowed.

FOOD

NO personal belongings are allowed at Girls Inc, including cell phones, backpacks, electronics, keys, loose jewelry, etc. 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 a regular part of Girl Inc.'s summer program. Girls may participate in walking or transported field trips. It is important that Girls are dropped off on time to ensure they can attend field trips. Girls may NOT be picked up at a field trip location.

FIELD TRIPS

Comprehensive sex education is delivered to ages 12 and up.

SEX EDUCATION

Comprehensive sex education is delivered to ages 12 and up.

Once registered and accepted, dues for the entire summer are applied. Fees are invoiced each week, per child on a sliding scale. You will be informed of your rate prior to enrollment confirmation. Fees are due each week. 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.

FEES 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 summer at Girls Inc. Keeping up with your child's summer on Class Dojo is essential.

PARENT/GUARDIAN SUPPORT

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

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. without refund and that I will be responsible for any additional weeks for which I registered. I further acknowledge that any fee paid is nonrefundable and that I will be held responsible for any and all weeks for which I have registered, whether my child attends or not.

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.

Refund/Cancellation Policy*

I understand and agree to the refund/cancellation policy.

If cancelled by May 16 - refund of any fees paid, less a $25 administrative fee

If cancelled after May 16, but before program begins, refund of any fees paid less the $90 activity fee

If cancelled after the program begins, no refund will be issued, AND you will be responsible for half of the fees of any weeks not yet paid.

Enrollment Certification*

I understand and agree.

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/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 guaranteed and is not complete until I have submitted/completed all required forms and fees.

Signature*

FEE/BILLING INFORMATION

For your convenience and greater accuracy, Girls Inc. now bills electronically only. Invoices will be sent automatically each week to the e-mail address you provide below (fees are due one week in advance). While 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.

Preferred e-mail Address for Billing*

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

Re-enter e-mail Address for Billing*

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. This is also the form used to establish your fee for the 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.

PAYMENT OF ACTIVITY FEE

Once this registration is received, you will be invoiced by e-mail for the Activity Fee. NOTE: no registration will be considered complete until the activity fee is paid in full.

Girls Inc. is the longest-running  girls’ leadership program.

Girls Inc. is building the new generation of strong, smart, and bold leaders through direct service and advocacy.

Girls Inc. programs enriches lives!

Get Involved

Summer 2025

CHILD'S INFORMATION

CHILD'S HEALTH DETAILS

CHILD'S CONCERNS/BEHAVIOR/HISTORY

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS

PARENT AND GIRL POLICIES AND RESPONSBILITIES

RELEASE/CONSENT/WAIVER

FEE/BILLING INFORMATION

IOWA ELIGIBILITY APPLICATION

PAYMENT OF ACTIVITY FEE

Join The Movement

Girls Inc. is the longest-running girls’ leadership program.

Girls Inc. is building the new generation of strong, smart, and bold leaders through direct service and advocacy.

Get Involved

Summer 2025

CHILD'S INFORMATION

CHILD'S HEALTH DETAILS

CHILD'S CONCERNS/BEHAVIOR/HISTORY

PARENT/GUARDIAN INFORMATION

EMERGENCY CONTACTS

PARENT AND GIRL POLICIES AND RESPONSBILITIES

RELEASE/CONSENT/WAIVER

FEE/BILLING INFORMATION

IOWA ELIGIBILITY APPLICATION

PAYMENT OF ACTIVITY FEE

Join The Movement

Girls Inc. is the longest-running  girls’ leadership program.