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Academic Girls Empowering for Success


Membership Application 2018-2019

Personal Data Form

Application Date ________________________________

Name ________
Address City State Zip
Email Home Ph. Cell Ph.
School Current Grade Level Age Birth Date
Social Media Page
Address City State Zip
Email Home Ph. Cell Ph.

Fees include: New Flowers $125 ________________ (include application, registration and induction items)

Method of Payment check #___________ CC ________________________ Exp Date_____________ Cash _____________

T-shirt size: S____ M ____ L _____ XL _______


Community and Church Activities

School Activities

Signature of Candidate Signature of Founder

Signature of Parent/Guardian Date Received

Induction Date

Academic Girls Empowering for Success
Medical Release Form

Name ____________________________________________________________________________

Address ________________________ City _____________________ State ___ Zip ___________

School _____________________________________ Current Grade Level ________ Age ______

Birth Date____________________ Email ______________________________________________

Doctor Name ______________________________________________________________________

Address _________________________________________ Phone __________________________



Hospital Preference



I authorize representatives of AGES to administer health cautions to my child and to get them to
the nearest medical facility for professional and quality care. To notify me of the situation and
to provide the information of the incident. A complete incident report will be provided with
detail information about the incident. I approve for basic over the counter medication(s) to be
provided unless otherwise prohibited. I will not hold AGES or its representative’s liable for any
injury to my child at any time during their participation of the program.

_____________________________________ ________________________________
Signature of Participant Signature of Parent/Guardian

______________________________________ _________________________________
Date Date

Academic Girls Empowering for Success (A.G.E.S.)
Photograph Release Form

Academic Girls Empowering for Success (A.G.E.S.) participants will often be photographed to
chronicle activities of the projects committees, photos are often taken for documentation.
These photos may be used by members of Academic Girls Empowering for Success
and its agents in the following manners:
 Scrapbooks
 Newsletters
 Reports
 Displays
 Publications

I give AGES permission for ________________________________ to be photographed while

participating in activities in conjunction with the purposes and goals of Academic Girls
Empowering for Success (A.G.E.S.) for the ________________ fiscal year.

____________________________________________ ____________

Signature of Parent or legal Guardian Date

Academic Girls Empowering for Success (A.G.E.S.)
Transportation Form

Flower ________________________________________________________

Address ______________________________________________________

Age ____________________ Grade __________________________

Parent/Guardian Consent
By my signature, I grant permission for my minor to ride from the Academic Girls Empowering
for Success (A.G.E.S.) or its designated representative to the location, community service
and social activities.
NOTE: Academic Girls Empowering for Success (A.G.E.S.) does not allow minors to ride
with drivers under the age of 25.

I understand and fully recognize that the transportation of my minor to participate in projects
and activities with Academic Girls Empowering for Success (A.G.E.S.) involves an element
of risk. The undersigned assumes all risk and hazards hereby incidental to such
participation and do hereby release, absolve, indemnify and agree to hold blameless AGES
or any of its representatives as assigned drivers and shall not hold AGES responsible for any
injury, illness or death as a direct or indirect result of said transportation.
Parent/Guardian please print name and signature

__________________________________ ______________________________

Print Signature

_______________ ______ ______

Month Day Year

Emergency Contact (person to contact if parent/guardian is unavailable)

____________________________________ _____________________
Name Phone Number

Academic Girls Empowering for Success (AGES)
Clothing Agreement
1408 E Henry St
Savannah GA 31404 912.224.6097

Dear Parents

As you know, there is a mandatory dress code to attend sessions of Academic Girl Empowering for Success
(AGES). Moving forward to make sure that everyone is informed of what the dress code is, please refer to the
following, sign and return with application materials.

Session attire: No pants, jeans, sneakers, or school uniforms

Induction attire: Black dress and yellow beaded necklace
Community Service attire: yellow or white t-shirt and jeans (photo opts require yellow t-shirt)
Social Bonding attire: yellow t-shirt or white t-shirt/jeans or casual (advisor will advise if something different
is required)
Dress down session: appropriate casual attire
Ceremonial events: Uninterrupted white with yellow beads and sunflower

This is the standard attire for all times when Flowers are required to do things in petal formation. Please know
that exceptions do occur please give timely notice to Founder Shipp or her designate if there is a concern. As
always, we are honored to water the Flowers of this Garden and look forward to a great year. Thank you.

Growing Flowers with a Purpose….

Yolandra Shipp
Founder Yolandra Shipp

____________________________ _____________________________
Seed Signature Parent/Guardian Signature

____________________________ ______________________________
Date Date

Academic Girls Empower for Success (AGES)
Paraphilia Order Form

Over the years we have accumulated several items that make AGES Flowers stand out in the crowd. Please
consider purchasing some or all of these items as they are often used at different times by the Flowers or as

Circle item(s) and list size

01Yellow t-shirt (this is given with the induction packet, but additional are available) $20
02White-t-shirt (optional – often used for community service projects) $20
03Black umbrella with AGES logo $12
04AGES Cap $12
05AGES Bracelet (replacement – initial is part of induction packet) $25
06Sunflower (replacement – received with induction) $10
07AGES Silk Club Jacket $65
08AGES Planner (replacement – received with induction) $25
09Tote bag (replacement – received with induction) $12
10Yellow Beads $5
11AGES Parent tee-shirt (Orange) $25

Item No. Size Quantity Total

_______ _______ __________________ ______

_______ _______ __________________ ______

_______ _______ __________________ ______

_______ _______ __________________ ______

_______ _______ __________________ ______

Grand Total ______

Parent Signature