Girl Action Team Application

Participants Name*

First Last

Birth Date*

Email*

Phone*

Alt Phone

What School Does the Participant Attend?*

Current Grade*

Returning Participant?*

Yes

T-Shirt Size*

Relationship to Participant*

Title (Optional)

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Alt Phone

Email*

MEDICAL TREATMENT/FIRST AID AUTHORIZATION I grant permission for the administration of First Aid to my child by the staff of Girls For A Change (GFAC), and those transporting my child to and from programs as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when a delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/ guardian of the participant and emergency contact. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child. *

Allergies to Medications: Please type N/A in the boxes below if your child is not currently taking or allergic to any medications.*

Medications Currently Taking or N/A*

INSURANCE INFORMATION (OPTIONAL)

Policy Holder

Insurance Company

Policy #

Authorized Physician

Office Phone Number

Agreement Form for Transportation

Name*

First Last

Relationship to Participant*

Primary Phone*

I, the undersigned parent or legal guardian, release GFAC, or any other person acting on their behalf, from liability for any bodily injury sustained and loss or damage of any personal article while on the premises or participating in any activity provided by GFAC.

Unless a letter to the contrary is received, GFAC accepts your consent for us to take photos and share them on social media as well as GFAC main website.

Fairfield Middle School

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