Girls Inc. Online Membership Application For Parents

Once you complete the application, you will need to print it out and obtain the required signatures. You can also download the application here. Or if you would like an application form mailed to you, please call (212) 509-2000, ext. 228

PARENT OR GUARDIAN INFORMATION:

First and Last Name:

Relationship to Applicant:

Address (if different):

City:

State:

Zip Code:

Phone - Day:

Phone - Evening:

Email Address:

By signing below you are granting your child permission to participate in Girls Inc. Online, and you are acknowledging and agreeing to the following:

Girls Inc. Online is a free service for girls operated by Girls Inc., a not-for-profit organization. To maintain a secure environment for all girls, I agree to do my best to make sure that no one else but my child listed above accesses or participates in Girls Inc. Online. I waive any claim that I or my child might have against Girls Inc. arising out of my child’s participation in Girls Inc. Online, and will indemnify and hold Girls Inc., its officers, directors, employees and partners harmless as a result of my child’s participation.

I certify that I am the ___ parent or ___ legal guardian (please check one) of the child named above. I hereby grant my child permission to participate in Girls Inc. Online. I have reviewed the Code of Conduct and Privacy Policy with my child, and agree, for myself and for my child, to be bound by their terms.

Signature: _____________________________________________

Date: _________________________________________________

APPLICANT INFORMATION:

Please provide the following information about the girl applying for membership. All applicants must review the Girls Inc. Online Code of Conduct

First and Last Name:

Street Address:

City:

State (US only):

Zip Code:

Province/Country (international applicants):

Phone:

Email address:

Date of Birth:

Grade:

School Name:

School Address:

I have read the Girls Inc. Online Code of Conduct and as a member of Girls Inc. Online agree to behave accordingly. I understand that Code of Conduct violations may result in termination of my membership in Girls Inc. Online.

Signature: _____________________________________________

Date: _________________________________________________

THIRD PARTY VERIFICATION:

Have this form signed by a teacher, school counselor, principal, other school official or Notary Public. This form cannot be signed by a parent, grandparent, sibling or other relative.

Name:

Title:

Organization:

Email Address:

Phone:

FAX:

I verify the identity of the above applicant.

Signature: _____________________________________________

Date: _________________________________________________

When all three parts are completed fully, please FAX the application to (212) 509-8794, Attention: Girls Inc. Online.

If you prefer, you can send us the application by mail to:
Girls Inc. Online
120 Wall Street
Third Floor
New York, NY 10005

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