Girlz Climb On Application - Please Read Carefully

Thank you for applying for Girlz Climb On. There are 2 parts to the application. It will take about 10 minutes to fill in.

Part 1 – Participant and Family Information
Parts 2A and 2B – Parent/Guardian Information

>> Part 1 - Applicant & Family Information

COURSE INFO

*GCO Location:  

Girl's Information

Girl's Name

First Last

Girl's Address

Street

City State/Province Zip

Girl's Phone

Home Cell (optional)

Girl's Email (optional - we like to involve her in the process!)

Girl's Age

Birthdate (to determine program eligibility)

Grade

School

Girl's Shoe Size (because we provide climbing shoes)

Girl's Measurements

Height Weight (so we can select the right gear size for her)

Girl's Primary Language

Girl's Race/Ethnicity (our funders require we report this in who we're serving)  

Household Information

Household Income

Type

Do you plan to apply for Financial Aid?

How did you hear About GirlVentures? Please specify  

Medical Information

Insurance Provider

Name:

Is Pre-Authorization Required?

Carrier's Phone Number:

Policy/ID Number:

Doctor

Name: Phone Number:  

Emergency Contact Information

This should be someone other than the parent(s) and/or guardian(s)

Name:

Relationship to Girl:

Phone Number: Alternate Phone Number:  

Parent Information

Parent/Guardian Full Name Second Parent/Guardian Full Name