E4G Program Registration

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.*
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?*

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?*

Yes, we are Grays Harbor residents and wish to continue with our registration.NoWe 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?*

CMCBEmpowerment
Choose the correct program date*

February 25 - EmpowermentMarch 18 - CMCBApril 3-7 - CMCB week-longJuly 10-14 - Empowerment week-longJuly 17-21 - CMCB week-longJuly 31-August 4 - Empowerment week-longAugust 7-11 - CMCB week-longAugust 14-18 CMCB - week-longAugust 28-September 1 - Empowerment week-longOctober 21 - EmpowermentNovember 4 - CMCBDecember 16 - Empowerment
Is the child attending a resident of Grays Harbor county?

YesNo
Parent or Guardian*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Email*

Confirmation EmailPlease enter email twice for verification
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Person Attending*

First NameLast Name
Preferred Pronouns
Age*
Birthdate*

MonthDayYear
Date
Is this child in the foster care system?*

YesNo
Have you registered this child for any E4G programs in the past 2 years?*

YesNo
Are there any changes we should be aware of?*

YesNo
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*
Food Preference*

VeganVegetarianMeat Eater
3. Does your child have any medical conditions, allergies, or other health restrictions? Are they on any medications? *
Annual Household Income*
How many people are supported by your Annual Household Income?*
Racial Makeup of Household - Choose all that apply

American Indian or Alaska NativeAsianBlack or African AmericanHispanic or LatinoNative Hawaiian or other Pacific IslanderWhite
Does your child exhibit any behavioral, emotional or developmental challenges?*

AnxietyDepressionSuicidal Thoughts or ExpressionAggression Toward OthersSelf-HarmLearning DisabilitiesNone of the Above
Please explain the above choices.*
How do you think this program will benefit your child and your household?*
What are some of the expectations you have in your child attending this program?*

Positive Body ImageBecome More EmpoweredIncrease ConfidencePuberty/Menstruation EducationGender Identity/Sexual OrientationBuilding Healthy RelationshipsConsent/BoundariesResiliencyStress ReductionConnecting with OthersSocial Media AwarenessNeeded a Place for My ChildOther - Please Explain Below:
Please explain Other expectations
How did you hear about us?*
Are you applying for a Scholarship?*

YesNo
Would you like to place a deposit or pay in full?*

DepositPay in full
Is the person attending a member of Girl Scouts of Western Washington?

YesNo
Would you like to Power Up to support our Scholarship Fund?*

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)*
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.*

YesNo

Remaining Balance Due
Should be Empty:

Credit Card Details
First Name	Last Name
Credit Card Number	Security Code
Card Expiration

E4G Program Registration

Sorry, the program you've chosen is full. Please complete the form to be placed on the waitlist or select a different program.

Pre-Program Questionnaire