Enroll in GEM Programs

Girl's Name*
First Last
Girl's Date of Birth*
Race/Ethnicity*
School Attending*
Grade*
Girl T-Shirt Size*
Were you referred to us by Prison Fellowship Angel Tree or Opportunity Kids Collaboration?*
- Yes
- No
Address*
Street Address Address Line 2 City State ZIP Code
Any allergies or special health concerns that we may need to be aware?*
- Yes
- No
Please describe in detail*
Any medications?*
- Yes
- No
Describe Medications*

Parent/Guardian Information
Parent/Guardian Name*
First Last
What is your relationship to the girl you are enrolling in GEM?*
Email*
Cell Phone*
Home Phone
Work Phone
Address*
Street Address Address Line 2 City State ZIP Code
I prefer to receive correspondence via:*
- Text messages
- Email
Mother Information
Is the girl's mother currently incarcerated?*
- Yes
- No
Mother's Name
First Last
Mother's Prison ID Number
Mother's Place of Incarceration (state and facility, if known)
Did girl reside with mother prior to her incarceration?
- Yes
- No
Emergency Information
Emergency Contact 1 Name*
First Last
Emergency Contact 1 Relationship*
Emergency Contact 1 Phone*
Emergency Contact 2 Name
First Last
Emergency Contact 2 Relationship
Emergency Contact 2 Phone
Other Information
The girl I am registering may be picked up from Girls Embracing Mothers' events by the following people ONLY:*
Do you qualify for the school lunch program?
- Yes
- No
Household Income
Number in household
Medical Information
Name of Health Care Provider

(i.e. Chip, Aetna, Unicare, Kids First, Parkland, BCBS)
Policy #
Doctor's Name
Doctor's Phone
Doctor's Address
Street Address Address Line 2 City State ZIP Code

The girl I am registering has my permission to be transported in vehicles owned or rented by Girls Embracing Mothers, Inc. and/or a representative of Girls Embracing Mothers, Inc. I agree not to hold Girls Embracing Mothers, Inc. liable for any injury or accident which might occur during her participation in the programs of Girls Embracing Mothers, Inc., including, but not limited to, transporting her for the purposes of participating in any Girls Embracing Mothers, Inc. program.

I hereby authorize Girls Embracing Mother Inc.’s use of the photograph and/or video image of the girl I am registering in printed materials for both internal and external promotional and corporate sponsor purposes. Girls Embracing Mothers, Inc. shall own all rights to such photographs or video images.

The girl I am registering has my permission to swim or engage in other physical activities (including other forms of exercise) during Girls Embracing Mothers, Inc. programming. I agree that I will not hold Girls Embracing Mothers, Inc. liable for any injury or accident that might occur while she is participating in such activities. I authorize Girls Embracing Mothers, Inc. to obtain medical care for the girl I am registering in the case of a medical emergency. I understand that I am financially responsible for the care given and that efforts will be made to contact me and/or the doctor of my choice.
Agreement*
- I agree and consent to the previous statements
Girls Embracing Mothers, Inc. does not discriminate on any basis prohibited by applicable law including race, religion, sex, national origin, disability, age and citizenship status.
Email
This field is for validation purposes and should be left unchanged.

Step 1 of 3 - GEM Girl Information

Parent/Guardian Information

Mother Information

Emergency Information

Other Information

Medical Information

Calling all GEMs!

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