Parent/ Guardian Name *

First Name

Last Name

Parent/Guardian Name

First Name

Last Name

Child Name *

First Name

Last Name

Phone *

(###)

###

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Emergency Contact *

Please list who we should contact in case of emergency

First Name

Last Name

Phone

(###)

###

####

I understand the following: *

I understand that by signing this form, I grant permission for my child to participate in the Girls That Rock mentorship program. I acknowledge that this program is designed to provide mentorship, guidance, and activities that foster personal and academic growth.

I understand that all participants are required to follow the general rules and program policies of Girls That Rock. Failure to adhere to these guidelines may result in dismissal from the program.

I understand that photographs and/or videos may be taken during Girls That Rock sessions and events. I give permission for my child’s image and likeness to be used in promotional materials, social media, and program-related publications. I also acknowledge that all media captured will be accessible to parents upon request.

Date *

MM

DD

YYYY