GIR

LS

INC

. HQ

1-3

98

BAYLY

ST

. W

AJAX

, ON

L1S

1P1

COST

: 

$25

/ M

ONTH

FOR

MEM

BERS

$40

/ M

ONTH

FOR

NON

-MEM

BERS

905

-428

-8111

GIRLS INC OF DURHAM

@girlsincdurh

am

@girlsincdurh

am

Upcoming Calendar

GIRLSPACE

GIRLS WILL DEVELOP LEADERSHIPSKILLS AND PARTICIPATE IN ACTIVITIES

THAT BUILD SELF-CONFIDENCE ANDHEALTHY COMMUNICATION.

Topics Include:

Operation SMART (STEM)

Allies in Action (Anti-Bullying)

Mind+Body

Leadership

FOR GIRLS AGES 6-12

WEDNESDAYS IN JANUARY ,MARCH AND MAY

6 :30-8 :30 PM .

to register check out our website

WWW.GIRLSINC-DURHAM.ORG

or hbuckner@durham.girls-inc.org

Where we inspire all girls to be strong, smart, and bold!

Subsidies

available

upon

request

Program PermissionI herby grant permission for my child________________________________________ to participate in Girls Inc. of Durham programming. I give my consent for her to participate in field trips and neighbourhood outingsarranged by the staff at Girls Inc.of Durham. Parents will be notified in advance of any such trips and may beasked to provide additional support depending on the outing. I understand that my daughter may be transportedby vehicle or walking, with adult supervision, in order to arrive at the destination. I understand that my medicalcoverage is the primary insurer for my child and will not hold Girls Incorporated of Durham responsible in case ofan accident or injury.

Parent/Guardian Signature: ____________________________ Date:_____________________

Media Release There will be occasions where pictures or videos of your daughter will be taken to be used in media projects forthe purpose of our program. These photos may also be used for public relation purposes, newsletter, brochures,annual reports, radio, television newspapers and our home website. o I give my permission for my daughter toappear in any Girls Inc. of Durham publications.

____ I give my permission for my daughter to appear in any Girls Incorporated of Durham publications.

____ I do not give permission for my daughter to appear in any Girls Incorporated of Durham publications

Signature: ____________________________ Date:_____________________

Registration FormChild's Name:____________________________________________________________________________Birthdate: M_____ D_____ Y_____ Age:_____ School:_________________________________Grade:_____Please indicate any medical information that you would like us to be aware of i.e. food allergies, medications,conditions etc._______________________________________________________________________________________Main ContactName:_______________________________________Relationship to Child: _________________________Address: __________________________________________________________ City: _________________Postal Code: __________ Home Phone: _______________________Cell Phone_______________________Email___________________________________________________________________________________Alternative/Emergency Contact Name:_____________________________Phone:______________________

Girls Inc. Membership Single $55 Family $70 Girls Inc. Members receive a 20% discount off of all programsMember Weekly $25 for 4 weeks Non Member Rate $40 for 4 weeks

___ GirlSPACE ___ GirlZONE ___ Membership

Location: Ajax _____ Payment Method: Cheque Cash Credit Card #_________ _________ __________ __________Expiry Date_________/________Name on Card: _____________________________Where did you hear about us?__________________________________________ ETAP TRAX