Girl's First Name (the “Participant”): *

Girl’s Last Name: *

Nickname (for name tag):

Name of School: *

Grade Level (PositivelyMe! is for 3rd Grade girls only)

Address: *

Address 2:

City: *

State: *

Zip: *

Age *

Date of Birth: *

T-shirt size of girl participant: *

Parent/Guardian's First Name: *

Parent/Guardian's Last Name: *

Relationship to Participant: *

Best Contact Number for Parent/Guardian (also to be used in the event of an emergency): *

Email Address for Parent/Guardian: *

Medical Information

Does the participant have any known allergies or other health issues or is she taking any medication(s) which should be made known to a treating physician or other health care provider? *

Yes

No

If yes, please describe:

Doctor’s Name in Case of an Emergency: *

Doctor’s Phone Number: *

Dentist’s Name in Case of an Emergency: *

Dentist’s Phone Number: *

Session Information

To participate in PositivelyMe! program, your child must be able to attend both days and stay for the full length of time. Please indicate which session she can attend in order of preference by marking a 1, 2, 3, or 4 next to each date (1=most preferred date) : *

	Session I – January 11 and January 12, 2018
	Session II - February 1 and February 2, 2018
	Session III - March 1 and March 2, 2018
	Session IV - April 5 and April 6, 2018

* Junior League House- 231 EAST Putnam Avenue, Greenwich, CT 06380

Name of person (first & last name) who will pick up the participant at the end of the program: *

Relationship of the person who will pick up the participant at the end of the program, to the participant: *

Phone number of person who will pick up participant at the end of the program: *

Alternative Emergency Contact Information

* Name of Person(s) to notify in case of an emergency(if Parent/Guardian cannot be reached)

First Alternate Emergency Contact Person: *

Relationship of First Alternate Emergency Contact Person to Participant: *

Phone Number of First Alternate Emergency Contact Person: *

Second Alternate Emergency Contact Person:

Relationship of Second Alternate Emergency Contact Person to Participant:

Phone Number of Second Alternate Emergency Contact Person:

Consent Form

**Signed release forms by a parent or guardian are required by the Junior League of Greenwich to participate in the PositivelyMe! program.**

Please click here and download the release form to complete and sign.

Please click here to find the PositivelyMe! Code of Conduct form. We request that guardians review the PositivelyMe! Code of Conduct with the participant prior to the program. Once the guardian and participant are clear on the content, both must physically sign the document.

**These forms should be either scanned and emailed, or mailed.**

Forms can be mailed to:

Junior League of Greenwich

Attn: PositivelyMe!

231 East Putnam Avenue
Greenwich, CT 06380

Please confirm your preferred method of delivery for the forms. *

I will mail the forms to the Junior League of Greenwich office by November 30, 2018

I will e-mail scanned forms to PositivelyMeJLG@gmail.com by November 30, 2018

* Please note, a memory group photo of the girls will be taken. Do you give permission for other photographs with your child to be used for public relations materials? No names or school information will be included. *

Yes

No

One last thing...

How did you hear about the PositivelyMe! program?: *