Piedmont Girl Power! 19-20
Please fill out the following form in order to register your child for Girl Power! at Piedmont. Girl Power! is geared towards 3rd-5th grade female identifying students. Programming will be after school on Wednesdays from 2:15 PM - 5:00 PM and a room is still TBD. Staff will contact families once changes are made in regards to what room students will be in.The week of October 7th will be our first week of program.

Please do not send your child to Girl Power! until you have received a confirmation call and/or packet from YWCA Girl Power! staff.

We will contact you as soon as possible after receiving submitted form. Call or email Saraiya Piantek, Program Coordinator 218-722-7425 x108 or Saraiya@ywcaduluth.org with any questions.
Child's Name *
Parent/Guardian Name *
Birthdate *
Address *
Teacher/Grade *
Phone Number *
Please list all phone numbers we could reach you at and mark the type of phone ex. C:(218)123-4567 W:(218)123-4567
Emergency Contact *
The parent/guardian(s) listed will always be the primary contact person. Staff will only contact adults listed below in situations where the parent/guardian cannot be reached. Emergency contacts are able to pick up child in event of emergency. Please list the NAME, PHONE, and RELATIONSHIP of at least TWO emergency contacts.
Photo Consent *
Mark below to agree or disagree to the use (without compensation) of the named child's photograph, videotape, or other likeness for promotional purposes and/or newspaper articles.
Medical Care In Case of Emergency *
Initial below, as a parent or legal guardian I do hereby grant authority and permission to the YWCA Girls and Youth programs to seek and permit medical care and treatment for the child listed in emergency situations where a medical care provider is unable to contact either me or my emergency contacts. The permission granted does not pertain in any way to reproductive health notice statuses.
Insurance Company/Policy
Preferred Provider
Medical Conditions *
Please list any medical conditions/medical needs/allergies/physical limitations that may affect your child at Girl Power! and any applicable care that we should know about.
Demographic Information
Girl Power! is able to provide FREE high quality programming to the Duluth community through grant funding. Many of our grants require us to report demographic information. Please note that providing us with this information is optional, but greatly appreciated for our reporting purposes.

Know that all information you provide is considered private data as defined by the Minnesota Government Data Privacy Act.
Household Income *
Using the table above and your total household income last year before taxes, please mark the income column for your family.
Please mark YES or NO for the following:
Qualify for Childcare Assistance Program
Verified for Free/Reduced Lunch by School District
Please mark YES or NO for the following: *
My child has attended Girl Power! before
A relative or friend of my child has attended Girl Power!
Family configuration living with this child *
Language(s) spoken at home:
Please mark ALL races that apply to this child: *
Comments & Signature *
Please list anything else we should know about your child, enrollment, or what you hope to get out of Girl power!
Activity Consent *
By marking my initials below, I hereby give my permission and approval for the child named on this form to participate in all programs and activities sponsored by or related to the YWCA Girls and Youth Programs. I assume all risks and hazards incidental to such participation (including transportation) and release these agencies (including board members, staff members, event sponsors, mentors, participants, and volunteers) from any claims arising from an injury to my child. NOTE: YWCA Girls and Youth Program staff will not solicit any information without first talking to parent/guardian.
Evaluation Consent *
For the purpose of securing and maintaining grant funding for our program, Girl Power! must access student records to demonstrate progress in our participants. By marking your initials below, you are agreeing to a release of school records and the administration of surveys for your child. This includes grades, standardized test results, attendance records, and survey results. All information will be kept confidential.
Signature *
By writing my name below, I agree that a photocopy or fax of these authorizations may be used in lieu of the original to obtain information. I have read all the information on this form, have filled it out to the best of my ability, and consent to the above release categories. Please write your NAME and the DATE.
Please contact me regarding donating to Girl Power! *
Girl Power! is able to provide free school year programming and scholarships for summer camp programming so that all children may attend. We are grant funded, however, that means funding opportunities are always changing. With your donation, you would have the opportunity to allocate the funds as you see fit. Thank you.
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