Summer Application - Please Read Carefully

Thank you for applying for a GirlVentures Program. This application only needs to be filled in once during your participation with GirlVentures.

There are 4 parts to the application. It will take about 10 minutes to fill in.

Part 1 – Participant and Family Information
Part 2 – Parent/Guardian Information
Part 3 – Additional Household Information and Course Specific Information
Part 4 – Application Fees

Before applying, please read our Payment Policies. Thank you!

>> Part 1 of 4 - Applicant & Family Information

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 pack 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

Emergency Contact

Name:

Relationship to Girl:

Phone Number:   Alternate Phone Number:

Parent Information

Parent/Guardian Full Name

Second Parent/Guardian Full Name