PowerUp Girls for Life Program Registration


Scott Elementary School, Greeley

Scott Elem logo.png

5TH GRADE PROGRAM

Host partner, Kimberlee Perales

Starts in February. Contact Ms. Perales for the schedule!

kperales@greeleyschools.org

970-348-2243


Registration Form

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

Para registrarse en español, haga clic aquí.

Para información del programa en español, haga clic aquí.

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 having 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, your have read the curriculum on the topics and skills taught, you have no questions or concerns, you agree to all the terms of the consent, and hereby give permission for your child to participate in the program.

AFTER FILLING IN the above FORM AND CLICKING the ORANGE "SUBMIT REGISTRATION" BUTTON:

Please consider making a small donation by clicking the orange “Donate” button to defray our costs and help us serve more girls and develop more programs. No PayPal account needed. Just click the gray "Pay with debit/credit card" button while in PayPal. Thank you very much!

 
 

After we receive your form submission, we will notify you by e-mail.

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), you verify all of the following as required by the program creators and 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), and have no questions or concerns about your child learning about listed topics and other related topics.

3.    Your registered child is a 5th grade girl.

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 that you and your child will follow and comply with your host’s check-in and check-out procedures, which are at their discretion.

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. You understand that host partners and their venues are not affiliated with Youth Empowerment Group, and you will not hold us or them liable for injuries, accidents, or any other harm related to participation in host partner programs.

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 full, unlimited utilization of photographs or videos of your child taken during her involvement in the program at all program locations for promotional purposes and waive all rights of compensation.

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 enjoyment of the activities. You also agree to do a quick anonymous parent-guardian survey after the program. Lastly, you permit us to use summaries of any survey data or anonymous participant quotes in research studies, on our website, or in print materials, etc.