Girls Rock! RI Gender Discussion Group Fall 2018 Registration Form
Hello future discussion group participants (and parents/guardians)!

This registration form is for Gender Discussion Group with Girls Rock! Rhode Island. Please fill out this form to get your participant on board. Participants must be 14-18 years old (or currently in 9th-12th grade). We welcome girls, women, trans, and gender non-conforming individuals in our programming.

Gender Discussion Group will be held every Monday from 4-5pm at our program space at 769 Westminster Street on the West Side of Providence. The fall session of gender discussion group will start September 24th and run weekly through December 10th. We will follow the Providence Public School Calendar (no discussion group on Monday holidays or when school is canceled due to snow).

Gender Discussion Group is free, however you must fill out this registration form. Your weekly attendance is required to participate in order to build trust and create a cohesive group.

Don't forget to click "submit" at the end of the form to complete the registration!

Thanks!
Girls Rock! RI

Participant Info!
Youth participant's first name *
Your answer
Youth participant's last name *
Your answer
Name youth participant prefers to be called by instructors
If different than above
Your answer
What gender pronouns does the youth participant child use? (optional)
i.e. she/her/hers, they/them/theirs, he/him/his, etc. We ask only so that we have a sense of how your child would like us to refer to them.
Your answer
Youth participant's email address *
Your answer
Youth participant's phone number *
Your answer
How do you prefer to communicate? *
Street Address *
Where you receive mail
Your answer
Apartment/unit/floor #
Your answer
City *
Your answer
State *
Your answer
Zip Code *
Your answer
Age *
Participants must be 14-18 years old to attend Gender Discussion Group
Your answer
Date of birth *
MM
/
DD
/
YYYY
Grade *
School attending *
Your answer
What type of school is this? *
What time is dismissal at this school on Mondays? *
Time
:
Can you commit to attending Gender Discussion Group every week (barring sickness or major issues)? *
If you selected "no" or "maybe" above, please explain your hesitation to commit below: *
Your answer
Parent/Guardian Contact Info!
First name of primary contact/parent/guardian *
Your answer
Last name of primary contact/parent/guardian *
Your answer
Relationship to participant *
Your answer
Primary contact's phone number(s)
Cell
Your answer
Home
Your answer
Work
Your answer
Primary contact's email address *
We use email as our main mode of communication so please submit an email address that you check frequently
Your answer
What is the best way to contact you? *
First name of secondary contact
In case of emergency only.
Your answer
Last name of secondary contact
In case of emergency only.
Your answer
Relationship of secondary contact to participant
Your answer
Secondary contact's phone number(s)
Cell
Your answer
Home
Your answer
Work
Your answer
Secondary contact's email address
Your answer
What is the relationship of the secondary contact to the primary contact?
Your answer
More About You!
To be filled out by the youth participant
What topics are you interested in talking about? *
Some examples of topics that we've discussed in the past include: Healthy Relationships, Mental Health, Beyonce, Gender Roles in Film, LGBTQ+ Issues, and more -- we pick one topic per week.
Your answer
Have you participated in other programs at Girls Rock! Rhode Island? *
If you have participated in other Girls Rock! RI programs, which ones have you participated in? *
If we offered other programs, what else would you like to learn/do/talk about?
Your answer
How did you hear about Girls Rock! RI's Gender Discussion Group?
Your answer
More About Your Child!
Demographics, medical issues, etc. (To be completed by a parent/guardian)
Racial/ethnic identity (optional)
Creating a group of participants that reflects the diversity of Rhode Island is a priority for our programming. In addition, some of our funders require the racial/ethnic and economic make-up of our program population to be documented. Providing the following information will help us meet our diversity goals and help us continue to receive funding for future sessions. Check any that apply.
Language needs
Gender Discussion Group is conducted in English. If your child's primary language is other than English we will do our best to find interpretation assistance, but cannot guarantee availability. If your child would like interpretation assistance during gender discussion group, please indicate their preferred language here:
Your answer
Medical conditions/allergies/dietary restrictions
Does your child have any medical conditions, allergies, dietary restrictions, or other issues that the staff should know about? All medical information will be kept confidential and shared only with necessary staff.
Your answer
Behavioral/emotional/social issues
Does your child have any behavioral, emotional, or social issues the staff should know about? We ask so that we can best serve our participants and have adequate staff on hand if special attention is needed. Again, all personal information will be kept confidential and shared only with necessary staff.
Your answer
Does your child have friends or relatives who are also attending Gender Discussion Group?
If so, please list their name(s) below:
Your answer
Almost Done! Click "SUBMIT" below!
To complete your registration: Make sure to click SUBMIT on this form!

We will send you a confirmation email to let you know that we've received your registration form.

Questions? Visit www.girlsrockri.org or contact Rachel Sholly, Interim Program & Operations Coordinator, at rachel@girlsrockri.org or 401-443-2873

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