Girls Rock! RI Band Booster Fall 2018 Registration Form
Hello future Band Booster participants (and parents/guardians)!

This registration form is for Band Booster with Girls Rock! Rhode Island. Please fill out this form to get your participant on board. Participants must be 11-21 years old. Cisgender boys may participate in Band Booster, but 50 percent of the members of each band must be girls, trans, or gender non-conforming youth.

Band Booster will be held weekly from 4-5pm at our program space at 769 Westminster Street on the West Side of Providence. There are three time slots available, which are first-come, first-served. The fall session of Band Booster will start September 24th and run weekly through December 10th. We will follow the Providence Public School Calendar (no Band Booster on holidays or when school is canceled due to snow).

Band Booster is free, however you must fill out this registration form. Your weekly attendance is required to participate in order to achieve the goals you set with your band. It is important that you respect your bandmates by attending regularly.

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 participant prefers to be called by instructors
If different than above
Your answer
What gender pronouns does the participant 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 they 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 11-21 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?
Can you commit to attending Band Booster 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 or Primary 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 goals do you hope to achieve as a result of attending Band Booster? What do you hope to do or learn? *
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 Band Booster program?
Your answer
More About You/Your Child!
Demographics, medical issues, etc. (If under 18, 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
Band Booster 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 you/your child would like interpretation assistance during Band Booster, please indicate their preferred language here:
Your answer
Medical conditions/allergies/dietary restrictions
Do you/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
Do you/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
Who else will be in your band?
Please list their name(s) and contact info below (your band members will also need to complete this form):
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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