Women On The Way 2019-2020
W.O.W. meets Thursday evenings from 7-9 at Granby Youth Services/ Senior Center. To apply to the program please fill out the registration form. Once we have received it you will get an email back confirming your reserved spot in W.O.W. Your place will not be secured until we have received a payment of $165 to Town of Granby 15C North Granby Rd., Granby, CT 06035 Attn. YSB W.O.W. begins October 3rd.
Email address *
Participant Name *
Your answer
Participant email *
Your answer
Participant phone number
Your answer
Parent/Guardian 1 Name *
Your answer
Parent/Guardian 1 email *
Your answer
Parent/Guardian 1 phone number *
Your answer
Parent/Guardian 2 Name
Your answer
Parent/Guardian 2 email
Your answer
Parent/Guardian 2 phone number
Your answer
Participant's Date of Birth *
MM
/
DD
/
YYYY
Participant's age *
Your answer
School *
Your answer
Grade *
Pronouns used *
Please give alternative if none of the above pronouns apply
Your answer
Demographics
Please check one for each category
Race *
Ethnicity *
Family *
Free/Reduced Lunch- scholarships available for those that qualify *
Permission and Emergency/Medical Information
If your child requires pick up, is there anyone NOT authorized to do so?
Your answer
Emergency Contact *
Your answer
Relationship to student *
Your answer
Emergency Contact Phone Number *
Your answer
Are there any specific medical conditions and/or other information we should be made aware of?
Your answer
I agree to allow the YSB to use photographs, digital, and/or video images taken during W.O.W. in promotional materials and newsletters. *
My child has permission to fill out anonymous surveys. *
I'd like more information on a financial assistance.
In case of emergency, if I cannot be reached, I give my permission to the attending physician to hospitalize, secure necessary treatment for, order injections, anesthesia, or surgery for my child named on this form. Additionally, I the undersigned, do hereby waive and hold the Granby Youth Service Bureau, its employees and agents, harmless from any personal or property damage my child or I may incur while participating in this program. I also understand the Granby Youth Service Bureau does not provide accident or health insurance. *
In typing my name below, I am confirming that the above information is true and I am giving my full permission for my child to participate in programs at Granby Youth Services. *
Your answer
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