2021 Summer University - of Greater Atlanta - Girls Inc. of Greater Atlanta
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of Greater Atlanta
Summer University
2021
6th-12th grade Applica�on
www.girlsincatl.org
General Camp Informa�on
Address:
Atlanta Metropolitan State
College
1630 Metropolitan Pkwy SW
Atlanta, GA 30310
Telephone:
770-422-0999
Office Hours:
9am to 5pm
Camp Hours:
8:00am to 5:00pm
Week One: Week Three:
Monday, June 7, 2021 – Thursday, June 10, 2021 Monday, June 21, 2021 – Thursday, June 24, 2021
Week Two: Week Four:
Monday, June 14, 2021 – Thursday, June 17, 2021 Monday, June 28, 2021 – Thursday, July 1, 2021
*Special note Girls Inc. University “Girl Boss Camp” does not operate on Fridays. Every Thursday is Field Trip Day, Girls must wear their Girl
Inc Shirts* Closed Friday, July 2nd through Monday, July 5th in observance of Independence Day
02
Summer Kick-Off
A parent/guardian for each par�cipant is required to a end the mandatory parent orientation Saturday,
May 15th 1pm-4pm at the center.
There will be 3 groups at Girls Inc. University “Girl Boss”:
• Middle School Rising 6th thru 8th grades
• High School – Rising 9th thru 12th grades
Each group will have no more than 15 par�cipants to ensure social distancing. Girls Inc. University will fill up
quickly.
Registra�on Requirements
All of the following items are required in order for your registra�on to be complete. We apologize for any
inconvenience the addi�onal documenta�on adds. It is required due to our government funding, which enables
us to keep your costs low.
Complete Applica�on Packet for each par�cipant:
• $50 Processing Fee
• $125 Tui�on Fee per week
• Report Card (second or third quarter acceptable)
• Copies of photo ID for all listed parent(s)/guardian(s)
• Proof of all household income for persons in household (ex. pay stubs or receipts for the most recent four week
(1 month), Employer’s issued, signed and dated documentation, TANF records, Personal income ledger or
tablet (e.g. self-employed), alimony/child support, unemployment & disability income, armed forces income,
pension/retirement income) *additional examples below in the appendices.
If eligible include the following verification:
• Food Stamps
• Free and reduced lunch verification
• Peachcare for Kids
• Medicaid or Social Security Income
Registra�on materials can be dropped off in the locked mailbox in front of Girls Inc., by fax to 770-499-2386, or
by email to Bridget Trawick at btrawick@girlsincatl.org or Angelica Owen at aowen@girlsincatl.org. Ques�ons
specifically regarding applica�on materials can also be directed to Bridget Trawick at the email address above.
Your registra�on is not complete, and your spot will not be held un�l we have received your completed
applica�on packet, and tui�on fees, this includes ALL suppor�ng documenta�on.
You may pay your tui�on fees through PayPal on our website at www.girlsincatl.org or Cash App ($girlsincatl).
Please note that when you register you are commi�ng to pay for the en�re session. Girls Inc. does not have
daily rates.
The par�cipant will be required to wear a mask daily.
03Programming Schedule
This Summer girls will par�cipate in specialized camps. Each girl will be enjoying up to 3 hours a day in their
desired area of concentra�on in addi�on they will engage in other ac�vi�es such as Academic Enrichment,
Healthy Lifestyle, Wellness, Informal Time etc. Spaces are limited.
Girls Inc. University “Girl Boss”
A business and entrepreneurship program that will cover leadership skills, community advocacy, and financial
management through mentorship. This program will take place on the campus of Atlanta Metropolitan College.
During the “Girl Boss” sessions, our expert instructors will teach our girls about the different types of businesses,
corpora�ons, non-profits, entrepreneurship, and alterna�ve self-employment. We will teach girls about what it
takes to start their own businesses including how to develop a product, create a marke�ng plan and par�cipate
in a sales day or Girls Inc. store at the end of the session.
Girls will be working with mentors from corpora�ons around the Greater Atlanta Area, that will serve as their
business coach for the en�re camp. They will also have virtual seminars on business & finance from some of the
top Girl Bosses in the city.
You will receive a specific schedule for your child’s group at parent orienta�on.
A�endance
Girls Inc. University Summer hours are from 8:00AM to 5:00PM. Girls will not be allowed to be dropped off early
even if staff are present in the building as this prevents staff from preparing for the day. All girls are to be picked
up by 5:00PM, unless they are catching the shu�le or late pick-up fees will be assessed.
04Payment Policies
Tui�on Fee: The tui�on fee is $125 per week.
Tui�on Responsibili�es: There will be no tui�on refunds if a par�cipant does not a�end due to illness,
transporta�on issues, or other unforeseen circumstances. Refunds will also not be issued if the par�cipant is
dismissed due to behavior. The par�cipant will not be allowed to a�end if registra�on is not completed in full.
Payment Op�on: You may pay your tui�on fees through PayPal on our website at www.girlsincatl.org or Cash
App ($girlsincatl) or by calling Bridget Trawick at 678-686-1740 ext. 229 to take payment via phone. No cash or
checks will be accepted in person.
*Please make sure you include your child’s name when making payments.
Late Pick-up: Girls Inc. Summer University closes at 5:00 PM. Late pickup fees begin to accrue at 5:05 PM, a�er
which you will be assessed a fee of $1.00 for every minute you are late. Late pickup fees are due within one
week of when they are incurred. In the event of consistent late pick-ups, or extremely late pick-ups Girls Inc.
reserves the right to increase fees or even dismiss par�cipants from the program.
Scholarships
Scholarships are available based on need as assessed by family income and size. Once you have completed
your applica�on our staff will contact you within 3 business days to inform you of your scholarship. You may
submit your applica�on without the tui�on fee if you first need to know your scholarship rate before
commi�ng to registering, however no space will be held for your child un�l the tui�on fee is paid.
Below are the federal low-income guidelines that are u�lized by our funders to determine funding eligibility.
This is for your informa�on only and does not affect your par�cipa�on in this program.
CDBG MAXIMUM HOUSEHOLD INCOME LIMITS
Household Extremely Low 30% Very Low-Income 50% Low Income 80%
Size
01 $17,400 $28,950 $46,350
02 $19,850 $33,100 $52,950
03 $22,350 $37,250 $59,550
04 $24,800 $41,350 $66,150
05 $26,800 $44,700 $71,450
06 $28,800 $48,000 $76,750
07 $30,800 $51,300 $82,050
08 $32,750 $54,600 $87,350
FY2020 Income Limits
*Source: U.S. Department of Housing & Urban Development [HUD] Effec�ve: July 1, 2020
05Please review
pages 1 - 5
and
retain for your
records.
Pages 7 - 16
must be completed
and returned with all
required
documentation.Member Informa�on Form
Please Print Clearly! Par�cipant Informa�on
New Member Returning Member
Legal Last Name: Legal First Name: Legal Middle Name:
Date of Birth: Age: Gender (Female, Male or Other):
School A�ending: School District: Grade (upcoming school term):
Home Address/P.O. Box/Apt #: City: State: Zip Code:
Is the student an ESOL* student: Yes No *English as a second language
What language(s) is spoken in your home? English Spanish Other
Ethnicity:
Black, Non-Hispanic White, Non-Hispanic Hispanic/La�no Asian
Hawaiian Na�ve/Pacific Islander Alaska Na�ve/American Indian Other
Is the student a special needs student? Yes No If yes, please specify the child’s special need(s):
Does your child have any disabili�es as iden�fied on the Individualized Family Service Plan (IFSP) or Individualized Educa�on
Plan (IEP). Yes No
Please check the week(s) your participant will attend:
June 7– 10, 2021 June 14– 17, 2021 June 21– 24,
24, 2021 June 28–July 1, 2021
Please list below your child’s top selections 1-4. (Middle and High participants can only select Business & Entrepreneurship)
Dance: STEM: Sports & Fitness: Business & Entrepreneurship:
Please select t-shirt size:
YSM YM YL AS AM AL AXL AXXL
Par�cipant lives with:
One Parent Group Home Both Parents Grandparents
Guardian/Caregiver Foster Home Other
How many people are in your household?
If different than parents/guardians
Par�cipant's Phone Number: Alternate Phone Number: Par�cipant's Email:
07How did you hear about Girls Inc.?
I (print name) ____________________________ cer�fy that all the informa�on given in this form is correct and true to the best of
my knowledge. I understand that providing false informa�on may result in my child not being able to par�cipate in the a�erschool
care program.
________________________________________ ____________________________________
Parent or Guardian Signature Date
Medical & Behavioral Informa�on
Please list any medical informa�on we should be aware of including any allergies, medica�ons,
diagnoses or other concerns.
Please include any way these condi�ons or behaviors may need addressed or accommodated. For
example, if your child has been diagnosed with ADHD and/or Au�sm, please describe behaviors we should
expect to see or if there are behavior modifica�on techniques (incen�ves or disciplines) used at home or at
school. This will help us work with you as a team to help your child succeed and ensure that your child
receives consistent messages to avoid confusion. Please a�ach addi�onal informa�on or discuss this with
us as necessary.
08Contact Informa�on Form
Primary Parent or Guardian Contact During the Summer
First Name: Last Name: Rela�onship to par�cipant:
Email: Address:
City: State: Zip: County:
Best phone # to reach you: Phone Type:
2nd phone # to reach you: Phone Type:
Secondary Parent or Guardian Contact During the Summer
First Name: Last Name: Rela�onship to par�cipant:
Email: Address:
City: State: Zip: County:
Best phone # to reach you: Phone Type:
2nd phone # to reach you: Phone Type:
Other contacts authorized to pick up child.
Name: Phone: Rela�onship:
Name: Phone: Rela�onship:
I have provided Girls Incorporated of Greater Atlanta with all necessary medical informa�on and can be reached at the
numbers listed. I acknowledge and accept the risk for any accidents or injuries arising by reason of par�cipa�on in the program,
by myself or the person who is shown as the "par�cipant." I agree to indemnify and hold harmless Girls Incorporated of Greater
Atlanta officials, staff, officers, volunteers, and community partners harmless from any accidental injury or loss of property that
may occur to the par�cipant or myself while par�cipa�ng in any of Girls Incorporated of Greater Atlanta’s programs.
Parent/Guardian Signature: Date:
09Acknowledgement of Girls Inc. Policies
I, ___________________________, parent/guardian of ___________________________, have read and
understand the payment policies that have been set forth by Girls Inc. of Greater Atlanta and included in
pages 2-9 of this registra�on packet. I acknowledge that it is my responsibility to adhere to all these policies
and make all required payments by the stated deadlines, including tui�on payments for the camp she
registers for regardless of a�endance. I acknowledge that I have been informed that this program is not a
licensed childcare facility. I also understand this program is not required to be licensed by the Georgia
Department of Early Care and Learning and this program is exempt from state licensure requirements.
Parent/Guardian Signature: _____________________________ Date: ____________________
I have reviewed and explained eligibility requirements and responsibili�es of the person who signed this form.
Girls Inc. Staff’s Signature: ______________________________ Date: ____________________
For Girls Inc. Use Only
Match the gross household income with the family size on the table below.
Does the household income fall within the guidelines? □ Yes □ No
If the total gross income of the household is at or less than the Federal Poverty Level (FPL) for the household size, the client is considered eligible.
Girls Inc. Staff’s Signature ________________________________________ Date _________________________
10Georgia Division of Family and Children Services
Afterschool Care Program
Youth Participation Eligibility Form
Page 1 of 3 - DFCS Afterschool Care Program Eligibility Form
Girls Incorporated of Atlanta, and the Georgia Division of Family and Children Services (DFCS) are partnering to provide valuable
out-of-school programs for youth in Georgia. The information provided on this form will help ensure that eligible youth are
benefiting from the partnership. Please complete this form in its entirety and return it to the identified staff person at the
program site. We thank you for your cooperation.
Form to be completed by Parent/Custodian/Caregiver
Youth Information – This section must be completed in its entirety.
Name of Youth Participant (Last) ___________________________ (First) ___________________________ (MI) _____
Social Security Number ______ - ______ - ______ Gender: ______ Male _______ Female
Date of Birth (mm/dd/yy): ___ ___ /___ ___ /___ ___
Is the youth named above in Foster Care within the state of Georgia Yes No
Note: If the youth is in Foster Care but not in the care of Georgia, please provide the state name _____________________________
Section 1
A. Is the youth applicant a U.S. citizen or qualified alien? Yes No
B. Is the youth applicant a Georgia resident? Yes No
C. Does the youth applicant fall into one (1) or more of the three categories below (Answer YES or NO and check all
categories below that apply to the youth)?: Yes No
____Youth applicant is between the age of 5 and 17 years old; OR
____Youth applicant is 18 years old and currently enrolled in school (high school, GED program or equivalent, or post
secondary institution) and will be enrolled in AND attend school during the upcoming academic year (Verification
of school enrollment includes a letter from the school on official school letterhead): OR
____Youth applicant is 18 - 19 years old and has a dependent child AND is the custodial parent
If one (1) or more answers to the questions in Section 1 is NO, the youth IS NOT eligible to participate in the DFCS funded services.
If the answer to ALL of the questions in Section 1 is YES, please complete the remainder of the form.
Section 2
Does the youth currently receive benefits or services under any of the programs listed below (Please Note: you will have to provide
official verification to the afterschool/summer program. See Appendix C for acceptable forms of verification):
Yes No
A. Temporary Assistance for Needy Families (TANF)
B. Supplemental Nutrition Assistance Program (SNAP) (also known as Food Stamps)
C. Medicaid or Social Security Income (SSI)
D. Reduced or free lunch program at school – Note: This eligibility is only for single youth eligibility.
This is not applicable if the entire school population is awarded free lunch in universal eligibility.
E. Peachcare for Kids
If the answer to at least one question in section 2 is YES, the youth is eligible to participate in the program and the
parent/custodian/guardian may complete Section 5. Verification for receipt of services checked in Section 2 must be provided and a copy
of the verification must be attached to this eligibility form. If the program does not receive verification of items checked in Section 2, the
youth will not be able to participate in the program.
If the answer to ALL of the questions in Section 2 is NO, the parent/custodian/guardian MUST complete Section 3, Section 4 and
Section 5 for eligibility determination. Verification for items listed in Section 3 and Section 4 must be provided and a copy of the
verification must be attached to this eligibility form.
Updated 9/2019Page 2 of 3 – DFCS Afterschool Care Program Eligibility Form
Section 3
If you answered NO to ALL of the questions in Section 2, please review the chart below and enter your family unit size, gross
household yearly income and gross household monthly income to determine eligibility.
Family Income Eligibility for the DFCS Afterschool Care Program Income Eligibility Guide
Number of Persons Federal DFCS Afterschool Care Program DFCS Afterschool Care Program
in Family Unit Poverty Level * Annual Household Income Guidelines ** Monthly Household Income Guidelines
1 $12,760.00 $38,280.00 $3,190
2 $17,240.00 $51,720.00 $4,310
3 $21,720.00 $65,160.00 $5,430
4 $26,200.00 $78,600.00 $6,550
5 $30,680.00 $92,040.00 $7,670
6 $35,160.00 $105,480.00 $8,790
7 $39,640.00 $118,920.00 $9,910
8 $44,120.00 $132,360.00 $11,030
Each additional $4,480 Multiply total Federal Poverty Level by Divide DFCS Afterschool Care Annual
person, add 300% Household Income by 12.
* Income based on the Office of the Secretary, U.S. Department of Health and Human Services (HHS) 2020 Poverty Guidelines for
the 48 Contiguous States and the District of Columbia. (Source: 85 FR 360, Page 3060-3061, Document Number: 2020-00858)
** 300 % of the federal poverty level in effect January 15, 2020.
Family Unit Size* _____
Gross Household Yearly Income $_______________Gross Household Monthly Income $________________
* See Appendix A for definition of family unit.
Section 4
Please complete Section 4 by listing your name, the name of the child (ren) who live with you, and the other parent of the child (ren) if
s/he lives with you. List any gross monthly income for each.
Household Composition and Income
Gross Monthly Income is income before taxes and deductions.
Name (First, Middle, and Last) Relationship Date of Birth Income Source Amount How often
(MM/DD/YY) received?
(Gross Monthly
Income)
SELF
Page 3 of 3 - DFCS Afterschool Care Program Eligibility Form
Updated 9/2019Section 5
Please review and sign Section 5 as notification and signature of verification.
Applicant Notification and Signature
We are asking for your youth’s Social Security number because any person applying for or receiving federal benefits must give
us his or her Social Security number. Federal law 409(a) (4) of the Social Security Act and federal regulations (45 CFR
264.10) allow us to collect this information.
By signing this application,
• I swear, under penalty of perjury, that to the best of my knowledge, all the information and statements I’ve provided in this
application are true, and
• I promise to cooperate with any effort to verify the information provided.
• If selected to participate in the program, I promise to abide by all rules and guidelines.
Parent/Guardian/Caregiver Information – This section must be completed in its entirety.
Name of Parent/Guardian/Caregiver (Last, First, MI) _________________________________________________
Street Address __________________________________ City ______________ State ______ Zip Code ________
Home Phone # _______________________ Work # _______________________ Cell# _____________________
________________________________________________ _________________
Parent/Caregiver/Guardian Printed Name Date
________________________________________________ _________________
Parent/Caregiver/Guardian Signature Date
Official Use Only Section for DFCS Funded Afterschool/Summer Service Provider:
Total Income: $______________ Per: Week Every 2 Weeks Twice monthly Monthly Household Size: _______
Annual Income Conversion: Weekly x 4.3333, Every 2 Weeks x 2.1666, Twice Monthly x 2, Monthly x 1
Total Converted Annual Income: $_____________ (Round to the nearest whole number)
By signing below, I certify the information presented within this form was reviewed, verified and confirmed** and meets the DFCS Afterschool Care
Program Eligibility rules and guidelines indicated within this form. I also certify this form will be kept in the youth participant’s file in a confidential and
secured location.
_____________________________________________ _______________________ __________________
Authorized Program Staff Signature Title Date
** See Appendix B for income verification proof sources
Updated 9/2019Page 1 of 2 - DFCS Afterschool Care Program Eligibility Form Appendix
APPENDICES
*Appendix A: Family Unit
The Department of Human Services Temporary Assistance for Needy Families (TANF) definition of family includes the dependent child
for whom assistance is requested and certain other individuals living in the home with the child who are required to be included in the
family.
The following individuals are considered members of the Family Unit:
• A biological or adoptive parent of the dependent child for whom assistance is requested;
• An eligible minor sibling, (whole, half or adoptive) of the dependent child for whom assistance is requested;
• Other children living in the home who are within the specified degree of relationship to the grantee relative but who are not
members of the Family Unit; and
• A non-parent relative who is the caretaker if there is no parent in the home or if the only parent in the home receives SSI.
**Appendix B: Income Proof Sources and Applicable Income Sources
Income verification must be obtained and a copy must be attached to the youth’s income eligibility form.
Examples of earned income verification are:
• Pay stubs or receipts for the most recent four weeks of earnings;
• W-2 Forms;
• Employer’s issued, signed and dated documentation;
• Personal income ledger or tablet (e.g. self-employed)
• Quarterly income tax returns;
• Annual income tax returns when presented in January – March quarter;
• Letter/statement from employer;
• Documentation from other DFCS staff such as the eligibility CM; and/or
• Form 809 or itemized statement completed by the employer.
Examples of unearned income verification are:
• Copy of current check with check stubs (within last 4 weeks);
• Award letters or written, signed and dated statement of payer;
• Social Security Records;
• Worker’s compensation records;
• Form 139 – Contribution statement;
• Unemployment insurance claim records;
• Georgia Gateway screen information; and/or
• STARS.
See page 2 of Appendix B for applicable income sources.
Updated 9/2019Page 2 of 2 - DFCS Afterschool Care Program Eligibility Form Appendix
Applicable Income
Each of the following sources of income is budgeted in determining eligibility:
Earned
• Wages or salary – Gross income of the applicant is used to determine eligibility
• Net Income from Self-Employment
• Employee commission
• Jury Duty
• Rental Income – (regular and ongoing payments – if engaged in management of property for an average of 20 hours or more per
week)
• Roomer Income – (regular and ongoing payments)
Unearned
• Military Allotments
• Cash gifts Charitable gift exceeding $300 received from and organization receiving state or federal funds
• Inheritances
• Insurance Benefits due to Loss of Income – benefits paid from an insurance policy due to loss of income
• Social Security Benefits
• Unemployment Compensation
• Worker’s Compensation
• Alimony – (regular and ongoing payments)
• Child Support – (regular and ongoing payments)
• Farm Allotment – payments received from government-sponsored programs, such as Agricultural Stabilization and
Conservation Services
• Veteran’s Benefits
• Capital Gains
• Interest/Annuity
• Capital Gains/Dividends
• Pension
• Trust Fund
• Disability Payment
• Boarder Income – (regular and ongoing payments)
• Rental Income – (regular and ongoing payments - if engaged in management of property for an average of 20 hours or less per
week)
• Deferred compensation through retirement plan
**Appendix C: Acceptable Verification of Benefits or Services
• Supplemental Nutrition Assistance Program (SNAP), Temporary Assistance for Needy Families (TANF), Medicaid, and
PeachCare: Official documentation showing the family/youth is currently receiving benefits at the time of
application/enrollment into the afterschool care program (Integrated Eligibility System (IES) documentation, Official Letter
from the Georgia Division of Family and Children Services outlining the receipt of benefits).
• Supplemental Security Income (SSI): Award letter from the Social Security Administration
• Free or Reduced Lunch: Award letter identifying free or reduced lunch as established by individual family eligibility. Note:
Programs may receive a listing of students receiving free or reduced lunch granted the listing is on official school letterhead
with the disclaimer that all free or reduced lunch eligibility is determined by individual family application. Universal, school-
wide, city-wide or district-wide free lunch does not qualify as an acceptable point of eligibility for the DFCS Afterschool Care
Program.
Updated 9/2019of Greater Atlanta
Inspiring all girls to be strong, smart, and bold
Atlanta Metropolitan State College
1630 Metropolitan Pkwy SW
Atlanta, GA 30310
770.422.0999
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