E4G Program Registration
**This form is for one program and for one child. Separate program registration forms must be filled out for additional registrants or programs.
Please select the Location,Week-long or One-day, the Program Title: "Conscious Minds Conscious Bodies" (CMCB) or "Empowerment", and Date of the Program you are registering for.
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Sorry, the program you've chosen is full. Please complete the form to be placed on the waitlist or select a different program.
Would you like to be added to the waitlist?
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Yes
Sorry, the program you've selected is full. Select "add me to the waitlist" or choose a different program.
Add me to the waitlist
Grays Harbor residents will be granted full scholarships funded by Grays Harbor Community Foundation in the amount of either $125 for a one day program or $395 for a week-long program. If you are a Grays Harbor Resident, please register only if you're certain that your child will attend the program. If you are not a Grays Harbor resident, you are welcome to register but will be required to pay the registration fee. Scholarships from the E4G Scholarship fund, however, can be requested and awarded below.
Would you like to continue with your registration?
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Yes, we are Grays Harbor residents and wish to continue with our registration.
No
We are not Grays Harbor residents, and would still like to continue with our registration.
Which program is this registration for: Conscious Minds Conscious Bodies (CMCB) or Empowerment?
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CMCB
Empowerment
Choose the correct program date
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February 25 - Empowerment
March 18 - CMCB
April 3-7 - CMCB week-long
July 10-14 - Empowerment week-long
July 17-21 - CMCB week-long
July 31-August 4 - Empowerment week-long
August 7-11 - CMCB week-long
August 14-18 CMCB - week-long
August 28-September 1 - Empowerment week-long
October 21 - Empowerment
November 4 - CMCB
December 16 - Empowerment
Is the child attending a resident of Grays Harbor county?
Yes
No
Parent or Guardian
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Email
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Confirmation Email
Please enter email twice for verification
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virgin Islands
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Person Attending
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First Name
Last Name
Preferred Pronouns
Age
*
Please Select
9
10
11
12
13
14
15
16
Birthdate
*
-
Month
-
Day
Year
Date
Is this child in the foster care system?
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Yes
No
Have you registered this child for any E4G programs in the past 2 years?
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Yes
No
Are there any changes we should be aware of?
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Yes
No
Pre-Program Questionnaire
Please take a moment to answer the following questions. All information provided will be stored securely. Personal information will only be shared with Empowerment 4 Girls Program staff and pre-screened camp volunteers, as needed.
Dietary Restrictions
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Food Preference
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Vegan
Vegetarian
Meat Eater
3. Does your child have any medical conditions, allergies, or other health restrictions? Are they on any medications?
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Annual Household Income
*
Please Select
$0-$16,910
$16,911-$25,750
$25,751-$34,590
$34,591-$43,430
$43,431-$51,500
$51,501-$60,340
$60,341-$69,180
$69,181-$77,250
$77,251-$86,860
$86,861-$103,770
$103,771-$117,030
$117,031-$130,290
$131,291-or more
How many people are supported by your Annual Household Income?
*
Please Select
2
3
4
5
6
7
8
9
10
Racial Makeup of Household - Choose all that apply
American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or other Pacific Islander
White
Does your child exhibit any behavioral, emotional or developmental challenges?
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Anxiety
Depression
Suicidal Thoughts or Expression
Aggression Toward Others
Self-Harm
Learning Disabilities
None of the Above
Please explain the above choices.
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How do you think this program will benefit your child and your household?
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What are some of the expectations you have in your child attending this program?
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Positive Body Image
Become More Empowered
Increase Confidence
Puberty/Menstruation Education
Gender Identity/Sexual Orientation
Building Healthy Relationships
Consent/Boundaries
Resiliency
Stress Reduction
Connecting with Others
Social Media Awareness
Needed a Place for My Child
Other - Please Explain Below:
Please explain Other expectations
How did you hear about us?
*
Please Select
Google Search
Google Ad
Facebook
LinkedIn
Friend or Family Member
School
Girl Scouts
Other
Are you applying for a Scholarship?
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Yes
No
Would you like to place a deposit or pay in full?
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Deposit
Pay in full
Is the person attending a member of Girl Scouts of Western Washington?
Yes
No
Would you like to Power Up to support our Scholarship Fund?
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Yes, I want to help remove financial barriers and expand access to E4G programs!
Not this time.
Enter a dollar amount below.
Your donation will help remove financial barriers and expand access to our programs. Thank you!
Balance
Payment Amount Calculation
How much can you financially contribute to the registration fee? (0-$375)
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Anything else you'd like us to know?
By accepting a scholarship you are utilizing donor-generated funds to cover registration fees. You acknowledge that these funds are finite and should be accessed only when there is financial need to do so. You are also agreeing to fill out a short feedback form after the program and review us on Google. This feedback is important for us to evaluate program success and share our impact with funding sources.
I understand and agree to the terms of accepting this scholarship and I have contributed what I can afford to the registration fee.
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Yes
No
Payment Amount
*
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USD
E4G Registration Fees
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First Name
Last Name
Credit Card Number
Security Code
Card Expiration
Remaining Balance Due
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