PowerUp Girls for Life Registration


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Weld County 4-H, Greeley

for 11- and 12-year olds

Fall, 2019 dates to be announced!

Please contact Kim Sterkel at ksterkel@weldgov.com or 970-400-2079 for more information

525 N. 15th Ave, Greeley, CO 80631


Registration Form

Before registering, please see the curriculum page for more information.

Name of parent or guardian *
Name of parent or guardian
Each child must be registered by a parent or guardian
Name of participating student *
Name of participating student
Please provide her legal name. (You may include a preferred nickname in parentheses.)
Parent or guardian phone number *
Parent or guardian phone number
To be used in the event of an emergency
Additional emergency contact name *
Additional emergency contact name
Additional emergency contact phone number *
Additional emergency contact phone number
Please fill in "none" or write in allergies to medications or foods
Which program location are you registering for? *
T-shirt size *
100% preshrunk cotton, Inches= dimensions of shirt laid flat
Name of parent or guardian signing consent form for child participation *
Name of parent or guardian signing consent form for child participation
Your detailed consent to have your child(ren) participate *
By clicking this button, you agree that as the parent or guardian indicated above, you have read all the consent information provided below, have reviewed the program curriculum on the program page, have no questions or concerns, agree to all its terms, and hereby give permission for your child(ren) to participate in the program.
Name on credit card for registration fee payment
Name on credit card for registration fee payment
After clicking the "Submit registration" button, please pay the below-cost registration fee of $40 using the PayPal link below (no PayPal account required). Thank you!
The nonprofit Youth Empowerment Group's mental health, education, and medical professionals welcome your questions about their program!

TO COMPLETE REGISTRATION, SUBMIT FEE HERE

After filling out the form AND clicking the submit registration button above, please complete your registration by paying the below-cost fee of $40 to program supplier Youth Empowerment Group using the “Pay Now” button below. No PayPal account needed—just click the gray "Pay with debit/credit card" button in PayPal.

 
Fee amount
 

Once your registration is complete, you will receive a confirmation e-mail. Please contact Program Coordinator Kim Sterkel at 970-400-2079 or ksterkel@weldgov.com with payment or schedule questions.

Thank you!


PowerUp Girls for Life Consent Information

By indicating your consent for your child to participate in the PowerUp Girls for Life program while registering online by clicking to fill the yes button on the registration form consent question, or by signing paper forms, you verify all of the following as required by the program creators, the nonprofit Youth Empowerment Group:

1.    You are the parent or guardian of the child registered to participate.

2.    You have reviewed the detailed curriculum on this website (click here to review the curriculum), have read all the consent information here, and have no questions or concerns about your child learning about listed topics and other related topics.

3.    Your registered child is an 11- or 12-year old girl at the time of the program.

4.    You understand that this program’s purpose is only educational and not therapeutic. If program facilitators identify a need that may benefit from psychological evaluation or therapy, referral information but not therapy will be given.

5.    You understand the following rules for participant conduct that will optimize the learning experience: respectful, non-disruptive behavior, following program facilitator directions, and keeping cellphones on silent and in a pocket or bag. If any of these rules are violated, you will be called to come and pick up your child.

6.    You agree to have a parent or guardian sign in and sign out your child everyday at the registration desk and to pick up your child each day by 15 minutes after the program end time.

7.    You, the parent/guardian, will not hold us, the program creators, our nonprofit Youth Empowerment Group company, our volunteers, or any individual affiliated with Youth Empowerment Group or PowerUp Girls for Life program liable for accidents, injuries or other harm related to program participation.

8.    Your child may be provided food and if she has food insensitivities or allergies, it is her responsibility to ask about ingredients in all food she chooses to ingest, and you have discussed this responsibility with her.

9.    You are aware that program facilitators including host partners are mandatory reporters of child abuse and neglect.

10. You permit utilization of photographs or videos of your child taken during her involvement in the program for promotional or educational purposes, waive all rights of use and compensation, and will not hold Youth Empowerment Group responsible for unforeseen events arising from such use. 

11.    One of our goals is to learn how to improve the program and assess how well we provide empowering life-skill education. By consenting, you agree to have your child participate in group verbal surveys and to fill out personal anonymous surveys during the program, indicating things such as understanding of the topics and skills, enjoyment of the activities, and suggestions for improvement. You also permit us to use any and all survey data or anonymous participant quotes in research studies, on our website, in print materials, grant or sponsorship information, or in other ways that further our ability to carry out our mission.