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Enroll My Daughter

Student Information

First name*

Last name*

Student's Birthday*

Month

Day

Year

Gender*

Male

Female

Other

Student's ethnicity (optional)

Student's address (where spends most of time).*

Student's grade and school they will be attending in 2024-25*

If your child is in 5th grade, please list their main teacher’s name:

Student Challenges: Please check all that apply.

Academic/School

Attendance

Behavior in school

Behavior at home

Attitude towards adults

Social skills with peers

ADHD

Unchallenged at school

English as a second language

Self-confidence

Self-control

Attitude

Other:

Please list any goals you have for your student or other important information you want us to know about your child: *

Parent/Guardian information

Guardian first and last name*

Relationship to student*

Email*

Phone*

Best time to reach you*

Second parent or guardian first and last name

Relationship to student

Email

Phone

Household information

How many adults live in household?*

How many children live in household?*

What is the primary language spoken in the student’s main household?*

Are there any other languages spoken in the home? Which language(s)?

Student health information

Does your child have any dietary restrictions or food, medication, or environmental allergies? Please list: *

Does your child have an Epi-Pen for allergies? *

Does your child have any other health or medical conditions? Please explain:*

Emergency Contact besides parent or guardian if you cannot be reached (Must be someone who lives in Central Ohio):

Name*

Relationship to student:*

Phone*

Please check one of the following boxes and sign below:

I grant Girls L.E.A.P. the right to use any photograph, video, or digital recording of my child in print and/or electronic form, including but not limited to, use on its website, informational materials, advertising and social media. I understand that there will be no financial compensation for the use of my child’s image at any time. I waive any rights, claims, or interest I may have to control the use of my child’s likeness and identity in whatever media used.

I do not grant consent for my child’s image to be used by Girls L.E.A.P. in any way.

Please check one of the following boxes and sign below:

I give my child permission to receive texts, emails and/or phone calls directly from their mentor.

Child's cell phone number and/or home phone number

Child's email address

I do not give my child permission to receive texts, emails and/or phone calls directly from their mentor.

Permission for Mentoring: I, the parent or legal guardian of the above student, consent and agree that my child may participate in the Girls L.E.A.P. mentoring program. I understand that information regarding my student’s progress in school subjects may be shared with program staff and my student’s mentor.

Signature*

Sign in the box or use the keyboard to type.

Signature field is empty.

Date*

Month

Day

Year