Girls Only Leadership Development 2018-2019 Registration
Participant Information
First name *
Your answer
Last name *
Your answer
Preferred pronouns (optional)
Your answer
What language(s) are you comfortable with? (optional)
Your answer
What race or ethnicity do you identify with? (optional)
Your answer
Grade as of Fall 2018 *
Your answer
School *
Your answer
Email address *
Your answer
Phone number *
Your answer
Home address (include zip code) *
Your answer
What is the best way to reach you? *
Please list any dietary restrictions, allergies or medical conditions that GOLD staff need to know
Your answer
Parental Guardian Information
Please provide information for at least one parent and emergency contact
First name *
Your answer
Last name *
Your answer
Email address *
Your answer
Phone Number *
Your answer
Address (include zip code) *
Your answer
Language(s) most comfortable in *
Your answer
First name (optional)
Your answer
Last name (optional)
Your answer
Email address (optional)
Your answer
Phone number (optional)
Your answer
Home address (include zip code) (optional)
Your answer
Language(s) most comfortable in (optional)
Your answer
Emergency Contact
First name *
Your answer
Last name *
Your answer
Relationship to participant *
Your answer
Phone number *
Your answer
Questions about you!
We want to get to know you, so that we can match you with a mentor that you can bond with throughout this program.
Rate your level of interest in the following topics *
I'm not interested at all
Kind of interested
Definitely interested
STEAM
Gender representation
High school/ career prep
Self efficacy
Financial lteracy
Leadership development
Why do you want to be a part of GOLD? *
Your answer
What do you hope to do/learn/experience in GOLD? *
Your answer
What is your greatest strength? *
Your answer
What is a skill you would like to improve? *
Your answer
What 3 words would you use to describe yourself? *
Your answer
Who is your biggest inspiration? *
Your answer
What qualities do you value in the people you spend time with? *
Your answer
Additional questions or thoughts?
Your answer
Parent/ Guardian Permission
As the parent/guardian of this participant, I hereby give permission for my child to participate in the Girls Only Leadership Development Program. I understand that participation in the Cambridge Girls Only Leadership Development Program will include the following activities: bi-monthly meetings at Cambridge City Hall or the YWCA Cambridge during the 2018-2019 school year; guest speakers; workshops; coordinated volunteer activities in Cambridge; visits to some of Cambridge's academic institutions; and a culminating celebration event. I understand that transportation for any outings for this program will either be on foot, public transportation or private transportation. I acknowledge and agree that my child may assume the risks associated with participation in the Girls Only Leadership Development Program, including field trips. I understand that my child will be obliged to abide by the guidelines of the Girls Only Leadership Development Program and the codes of conduct in the Cambridge Public Schools Rights and Responsibilities Handbook at all times. Failure to adhere to these guidelines may result in the dismissal of my child from this program. I further hereby give permission for my child to leave or return from any outings associated with this program by herself. By granting the permission as stated herein, I am releasing the City of Cambridge, the Cambridge Public Schools, the Cambridge Girls Only Leadership Development Program, the YWCA Cambridge, and their respective officers, directors, agents, employees and/or chaperones, from and against any and all liability, loss, damage, costs, claims and/or causes of action arising out or related to my child leaving or returning from these activities by herself. I also understand that the Girls Only Leadership Development Program reserves the right to cancel the approval for any activities if a change in circumstances, whether man-made or natural, would warrant cancellation of the activities in the interest of the safety of the students and staff of the Girls Only Leadership Development Program, and that the City of Cambridge and YWCA Cambridge will not be responsible for any financial obligations incurred as a result of the planning of these meetings or potential activities, or for any monies that are non-refundable or are otherwise lost due to the subsequent cancellation of the potential meetings/activities. By signing this Girls Only Leadership Development Program Permission Slip and granting the permission as stated herein, I am releasing the City of Cambridge, the Cambridge Public Schools, the Girls Only Leadership Development Program, the YWCA Cambridge, and their respective officers, directors, agents, employees from and against any and all liability, loss, damage, costs, claims and/or causes of action arising out or related to my daughter’s participation in this activity. I have read this Cambridge Girls Only Leadership Development Program Permission Slip and understand its terms. I sign it voluntarily and with full knowledge of its contents and significance. * *
Required
Media Release
As the parent/guardian of this participant, I hereby authorize the City of Cambridge and the YWCA Cambridge, MA to publish photographs taken of the undersigned minor and her name, for use in the City of Cambridge and the YWCA Cambridge’s printed publications, website and social media accounts. I attest that I am the parent or legal guardian of the minor listed below and that I have the authority to authorize the City of Cambridge and the YWCA Cambridge to use her photograph(s) and name. I release the City of Cambridge and the YWCA Cambridge from any expectation of confidentiality for the undersigned minor regarding promotional or other promotional materials I acknowledge that participation in any promotional materials (publications and/or websites) produced by the City of Cambridge and the YWCA Cambridge confers no rights of ownership whatsoever; therefore, I release the City of Cambridge and the YWCA Cambridge, its contractors and its employees from liability for any claims by me or any third party in connection with the participation of the undersigned minor. Any photographs or other promotional materials of GOLD activities including my child can be used for publicity and treated as property of the City of Cambridge and the YWCA Cambridge. *
Signature *
Your answer
Parent/Guardian Signature *
Your answer
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