PLI Teen Girls Group
Child's Name
*
First Name
Last Name
Did your child attend the Teen Girls Group this year?
Yes
No
Child's Birthday
*
-
Month
-
Day
Year
Date
Does your child have any allergies? Please write below.
Child's Grade
*
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
School Name
Child's Phone Number (if older than 12 years old and has phone)
Please enter a valid phone number.
Do we have permission to communicate with your child using the above phone number?
*
Please Select
Yes
No
Mother's Name
*
First Name
Last Name
Mother's Phone Number
*
Please enter a valid phone number.
Father's Name
First Name
Last Name
Father's Phone Number
Please enter a valid phone number.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Child's Age
Does your child have any allergies?
Please Select
Yes
No
What is your child allergic to?
Does your child take any medications?
Please Select
Yes
No
What medication does your child take?
Does your child have any behavioral issues we need to be aware of?
Please Select
Yes
No
What do we need to know about your child's behavior?
When did your family arrive in the United States?
-
Month
-
Day
Year
Date
Where are you from?
What language do you speak at home?
Do we have permission to take pictures or video of your child for PLI media?
*
Yes
No
Can we give your child minor medical treatment if needed?
*
Please Select
Yes
No
Does your child have permission to leave PLI to go home without supervision?
*
Yes
No
Who will pick up your child?
*
Mother
Father
Sibling
Friend
Other
I give my child permission to attend PLI's Teen Girls Group. I do not hold PLI responsible for any sickness or injuries that may happen to my child while there. I do not hold PLI responsible for my child once he or she leaves PLI property. I give PLI permission to seek medical care if my child should need it while attending this PLI program.
*
Submit
Should be Empty: