GirlSpace Registration 2020-21

GirlSpaceZ 2020 Registration Form

Please fill in the form below.
Which session will you be attending?

GirlSpaceZ Junior High: Tuesdays, 5:30 - 7 pm GirlSpaceZ Senior High: Mondays, 4:30 - 6 pm GirlSpaceZ Senior High: Mondays, 5:30 - 6:30 pm GirlSpaceZ Open Group: Thursdays, 5:30 - 7 pm
Participant Information
Full Name *

First Name Middle Name Last Name
Preferred Name:
Preferred Name
Pronoun(s) Used:
Age: *
Age of participant
Birth Date *

Month Day Year
Please select date
Primary Phone Number *

Area Code Phone Number
Secondary Phone Number

Area Code Phone Number
E-mail *
Address *

Street Address

Quadrant

City State / Province

Postal / Zip Code Country
Official Language Spoken: *
Other Languages Spoken:
Please list all applicable
(dis) Ability:
Ethnicity [Country of Origin}:
What is your legal status in Canada?

Canadian Citizen Permanent Resident Refugee Claimant

Parent/Guardian Information
Parent/Guardian's Name: *

First Name Middle Name Last Name
Relationship to Participant *
Primary Phone Number: *

Area Code Phone Number
Secondary Phone Number:

Area Code Phone Number
Email: *
example@example.com
Address: *

Street Address

Quadrant

City State / Province

Postal / Zip Code
Official Language Spoken: *
Other Languages Spoken:
Please list all applicable
Household Income Bracket (Please Choose One): *

$0.00 - $10,000 $11,000 - $15,000 $16,000 - $30,000 $31,000 - $45,000 $46,000 - $60,000 $61,000 - $75,000 $76,000 - $89,999 $90,000+ Prefer not to answer

Health Information of Participant
Does the participant have any medical conditions we need to be aware of? *

Yes No
If "Yes", please describe:
Please note: we recognize the importance of this information, and will do our best to make any necessary modifications to accommodate these needs.

Program Expectations
- Regular and punctual attendance ensures the group remains a safe and supportive space.
- I understand that this is a 20-week program. The start/end date differs depending on location.
- There is a possibility that new participants may not be allowed to join after a group has begun.
- Participants are encouraged to share their thoughts and feelings with the group. Participants will not share what they learn about other group participants.
- If the participant is no longer able to attend the program, written notice will be given to one of the group facilitators as soon as possible.
Participant Signature: *

Clear
Parent/Guardian Signature: *

Clear

Consent to Participate in Evaluative Research
Each consenting participant will be asked to fill out four questionnaires before and after the program related to the GirlSpace program on subjects including, resilience, leadership, mental health, and social connectedness. We will also be asking some of the participants to participate in a brief follow-up telephone interview about their experience in the program. Receiving your child’s feedback before and after the GirlSpace program will allow the evaluators to track important changes that are made while participating, and to revise the program for future participants. As the parent/guardian of the participant, I consent to participate in the current research project regarding my child’s experience in the GirlSpace Program. A consent form will be provided to you with further information.
Parent/Guardian Consent: *

Consent Do Not Consent
Parent/Guardian Signature: *

Clear
Participant Consent: *

Consent Do Not Consent
Participant Signature: *

Clear

Photo/Media Consent
As the parent/guardian of the participant, I consent to allow YWCA Edmonton to reproduce or distribute any photographs, video, film, audio or other similar material in association with the GirlSpace Program and related events/activities for promotional and/or archival purposes. There is no time limit to this consent; however, consent can be revoked at anytime with written notice to one of the facilitators.
Parent/Guardian Consent: *

Consent Do Not Consent
Parent/Guardian Signature: *

Clear
Participant Consent: *

Consent Do Not Consent
Participant Signature: *

Clear

Release of Liability
We, the Participant and parent/guardian, understand the information on this form is collected in accordance with relevant privacy legislation. We give permission for the information in this package to be used in the event of a medical emergency or to provide crisis support for the Participant. We authorize YWCA Edmonton to obtain medical treatment for the Participant and consent to medical treatment on behalf of the Participant. We acknowledge that in the event of an emergency, treatment may be provided to the Participant and that the parent/guardian will be financially responsible for any costs associated with such treatment or services (Example: ambulance transportation).

We hereby release YWCA Edmonton, its staff, volunteers and its insurers from any claims, demands, or actions in the event of loss, injury or damage to the Participant’s person or property, except when such loss, injury or damage is due to negligence on behalf of its staff or volunteers.

We understand that the Participant will follow the rules of YWCA Edmonton’s GirlSpace program that will be provided to them. If the Participant does not follow the rules they may be removed from the program.
Parent/Guardian Consent: *

Consent Do Not Consent
Parent/Guardian Signature: *

Clear
Participant Consent: *

Consent Do Not Consent
Participant Signature: *

Clear

Participant Agreement
I understand the purpose and expected activities of GirlSpace. I am aware that I will need to attend on a regular basis and not share what other participants talk about during the group. I am aware that I may revoke my consent to participate at any time and will do so in writing. I, the participant, agree to participate in YWCA Edmonton’s GirlSpace Program.
Participate Consent: *

Consent Do Not Consent
Participant Signature: *

Clear
Parent/Guardian Consent: *

Consent Do Not Consent
Parent/Guardian Signature: *

Clear

In Partnership With...
Safe Space
GirlSpace is Safe Space that welcomes and supports all members of the LGBTQ2S+ community.
Thank you for taking the time to complete the registration form! Please press "submit" below to complete the registration process. We look forward to having you join our program!
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