I hereby request and consent that my child or dependent your child's name here be permitted to participate in Empowered to Flourish after school program. I further understand that this program is designed to enhance self concept by guiding at-risk females in self-awareness, self-esteem and self-confidence and that my child will be required to attend and engage in program. I agree to media post unless otherwise specified. IParent Full Name and Child First Name Child Last Name (child's name) pledge to follow all conduct rules andacknowledge that my failure to obey rules and requirements may result in my removal from the program.