PEARLS, Inc. Mentoring and Empowerment group

PEARLS, Inc. Mentoring and Empowerment group

Participant Application
Name

First Name Last Name
Age
Must be 11-14 years of age
Birthdate

Month Day Year
Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Participant Contact Number

Area Code Phone Number
What are some activities that you like to do for fun?
What are some personal things that you’d like to work on? For example: I’d like to work on my social skills.
Do you have any known allergies?
Positively Empowering and Restoring Ladies Self-Esteem, Inc. is a girls mentoring and empowerment group that services young girls ages 11-14, primarily.
In order to participate, you must have permission from a parent or guardian.

By signing the box below, legal parents or guardians:

-Give permission for your daughter(s) to learn more about and eventually receive mentoring services.
-Understand that participants may be photographed or video recorded while in the program for promotional purposes only. Videos and photos will be used for social media sites and our website.

-Understand that parent/guardian is fully responsible for transportation

-Will communicate late pick-ups to Brittney Smith

-Understand that child may be removed from the program if involved in any activities of breaching the code of Conduct and Confidentiality Contract

-Understand that sessions may take place in the community, at different locations, and entities that are offering service projects

Please note: Parents/Guardians will be contacted to confirm permission.
Parent/Guardian Name

First Name Last Name
Parent/Guardian Contact

Area Code Phone Number
Parent/Guardian Email
example@example.com
Emergency Contact

Name Phone Number
Parent/Guardian Signature (use your finger to sign!)

Clear
Should be Empty: