Girls to Women Mentoring Hawaii Consent

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Thank you for your interest in our circles!

Girls To Women Mentoring Hawaii is a non-profit organization with 501(3)(c) status. We support, inspire and empower girls to become resilient, capable and confident through a program of evidence-based group mentoring circles led by trained adult mentors who have completed and cleared background checks.

Our girls circle is a structured support group led by adult women that allows for genuine self-expression through verbal sharing and creative activity. A group of up to ten girls of similar age and development meets for an hour - 90 minutes. The girls express themselves through creative or focused activities, oftentimes, themes are introduced which relate to the girls' lives - such as being a girl, trusting ourselves, friendships, body image, goals, competition, and decision-making.

For more information about our circles, or to ask further questions, please contact us gtwmhawaii@gmail.com or visit our website at www.http://girlstowomenhawaii.org

Parent/Guardian name: *

Youth name: *

Parent/Guardian Email address & Phone number: *

Youth Email address & Phone number: *

What is your preferred mode of communication? *

Text

Phone call

Youth Age *

Youth Date of Birth *

YYYY

Which Circle are you registering for? *

Ages 12 - 14 (2:30-4:00 pm)

Ages 15 - 18 (5:00-6:30 pm)

How did you learn about this program/offering?

Medical Agreement *

In case of an accident or emergency involving my child, I hereby give Girls to Women Hawaii authorization to call 911. I understand every effort will be made to contact me.

Required

Limits of Confidentiality *

All interactions occurring within the Girls to Women Hawaii Program, including other scheduled activities, and participant records are confidential. Girls to Women will not share information about your family or child without your prior written or oral consent. You may request in writing that the Girls to Women staff release specific information to persons you designate.

• The Girls to Women Hawaii staff works as a team. The Girls to Women Hawaii Mentors assigned to your child’s school may consult with the Girls to Women Hawaii Executive Team in order to provide the best possible experience for your child. These consultations are for professional and training purposes.

• If there is evidence of clear and imminent danger of harm to self and/or others, all Girls to Women Hawaii staff are legally required to report this information to the authorities responsible for ensuring safety.

• Hawaii state law requires that mandated reporters who learn of, or strongly suspect, physical or sexual abuse or neglect of any person under 18 years of age must report this information to the state Child Welfare Services.

• A court order, issued by a judge, may require Girls to Women Hawaii staff to release information contained in records and/or require a mentor to testify in a court hearing.

Required

Hold Harmless Agreement *

I understand that participation in any activity involves a certain degree of risk. I understand that the nature of Girls to Women activities are educational in nature not therapeutic, that participation in an activity is entirely voluntary and requires participants to abide by applicable rules and standards of conduct. I have given my child permission to participate in those activities. I release the staff, board members and volunteers of Girls to Women Hawaii, related parties, or other organizations associated with the activity from any and all claims or liability arising out of this participation.

Required

Media Release Agreement

I grant Girls to Women Mentoring Hawaii or other partners the right to use, reproduce, and/or distribute photographs, comments, video-recordings, sound recordings and other social media methods for use in any materials Girls to Women creates and uses for any appropriate and legal purpose.

I have read and understand all of the above information, and have had the opportunity to ask of Girls to Women Hawaii staff (gtwmhawaii@gmail.com) any questions I might have. Please sign and date *

Would you like to receive updates via email about Girls to Women Mentoring Hawai'i news?

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