Middle School Summer Retreat

Hello Guardian!

Dr. Paula Pilcher, ND, is so excited to share her teen empowerment program with your tween after seeing its powerful impact on teens since 2013!

This Middle School Summer Retreat will be interactive and engaging while nicely balancing physical activity, games, DIY labs, skill lessons, peer discussions, and practicing new life tools.

The lesson tools and activities in every retreat are designed to increase self-esteem, confidence, self-talk, body image, communication and conflict, healthy relationships, handling failure and rejection, managing emotions, relieving stress, having better nutrition, mindfulness, mental-physical-emotional-social health balance, and of course having LOTS OF FUN in the process.

They'll leave with memories for life and tools for life.

 

In order to make it the best experience possible for everyone, this registration form includes: retreat information, emergency contacts list, and permissions form. 

Please fill out, e-sign, and submit this form to register for the retreat and hold your tween's spot. There is an option to print the form to keep for your own records at the end. You will also receive an emailed copy. You will hear back from us at events@empowerteen.org with the payment link to finalize the registration.

Your spot is not held until payment is finalized. If you hear back from us that you've been placed on the waitlist due to full registration, be sure to keep the email address on your safe list so that you receive notice when an opening occurs and it doesn't go to your spambox.

All wait-listed registrations will be emailed at once and subsequently registered on a first response basis.

 

We have TWO LOCATIONS for the retreat. July 29-Aug 1 (Mon-Thu) will be at the Skyline Grange (11275 NW Skyline Blvd), and July 19 (Fri) we will meet in Washington Park, at Reserved Picnic Area A, in the Portland Rose Garden (400 SW Kingston Ave) for a special Park Gathering to close our week together.

 

WE MEET:  Please drop your teen off each day before 10am so that we may begin on time. Please have them picked up by 4pm. 

If you need help with carpooling, let us know... if you are willing to help out with carpooling, please let us know that, too.

 

We will send out an information sheet a couple of weeks before the retreat commences to remind you of the details, directions, and needs for your tween.

 

 

Your tween will look forward to the fun and variety of each day, while making new friends, bonding with their high school and college mentors and peers, and gaining more confidence in the process. What can we say? It's Empowerteen!

 

For questions about the retreat, or general information, please email

Grace Darazs, Event Coordinator College Intern, events@empowerteen.org or give her a call at 503-207-6284, ext. 109.

For anything you need Dr. Paula to know specifically about your tween's needs, email her at dr.paula@empowerteen.org, or call at 503-207-6284, ext. 104.

 

For more information about future events with Empowerteen, please go to https://www.empowerteen.org/events/ to get the latest updates.

 

• ___  Sack lunch (unrefrigerated)/ Water bottle/ Drinks
• ___  Medications needed (anti-histamine, inhaler, benadryl, epi pen, insulin, etc.)
• ___  Sun block/ Lotion/ Bug spray/ Chapstick (anything needed for outdoors)
• ___  Hats / Visors / Sunglasses (anything needed for sunshine or if we have rain)
• ___  Comfortable flexible clothing for stretching (buttons/ snaps/ zippers not ideal)
• ___  Good shoes for hiking and vigorous movement

All fields are required below. If nothing applies, please put "NONE" in the box. Thanks!

It is our policy to contact the parent or guardian as soon as possible in the event of a serious accident or injury. We will contact Guardian 1, then Guardian 2, then the Emergency Contact in that order. If we cannot get ahold of anyone after this process, we will activate emergency services by calling 911 if necessary. It is your responsibility to let us know if we need to be aware of potential health issues that may arise as the tween attends this summer retreat, and any modifications that are needed to prevent emergency situations.

COVID POLICY:

We will be following common COVID policies regarding camp. A copy of this policy will be included in the information sent out before the retreat starts. We will be spending 99% of our time outside and will only be inside to grab our bags and lunches and use the restroom. Hand sanitizer will be provided. Hand washing will be encouraged. It is your responsibility to notify us if your tween has had an exposure to COVID, demonstrates one primary symptom or two secondary symptoms, or has tested positive for COVID. We want to protect all involved in the retreat and the integrity of the camp.

By hitting submit and signing this form, I agree that I am the parent or legal guardian of the above named tween participant, I am over the age of 18, and all the information entered into this form is true and correct with nothing omitted. I agree that if any of this information changes that I will notify Empowerteen so in writing before the start of the retreat. In case of medical emergency or general medical care, I give consent for medical teatment for the aboved named tween participant by authorized personnel. I understand that the above named tween participant will only be discussed with the names listed above and the tween themself regarding information pertinent to this retreat. I understand that it is my responsibility to notify Dr. Paula if my tween is experiencing symptoms such as fever over 100 F, chills, cough, shortness of breath, difficulty breathing, loss of taste/smell, sore throat, headaches, muscle/body aches, fatigue, nausea/vomiting, congestion/runny nose, sinus pressure, diarrhea or any symptom that is unusual or new. I certify that my tween has my permission to attend this summer retreat and participate in all lessons, labs, discussions and activites unless I otherwise notify so in writing. I authorize Empowerteen to use my tween's picture, testimony, and video in any promotional material (web, print, or media) unless I otherwise nofity so in writing before the start of the retreat. My tween may also send and recieve any e-mails or messaging and Google Drive sharing files from Empowerteen regarding the retreat as well as participate in use of the Empowerteen Mobile App. I am aware that I will be receiving an email from events@empowerteen.org prior to the start of the retreat with detailed information regarding the retreat, as well as a survey to answer questions regarding DIY labs occuring at the retreat so that we may tailor the retreat to participants' needs, and I have added this address to my email's "safe" list to avoid missing messages by going to Spam. I also understand that my tween's spot will not be saved until payment confirmation is received from this address, that $50 of the retreat payment is non-refundable, and that registration is fully refundable (-$50) until July 8th, after which it becomes non-refundable. As this child's legal guardian I understand the inherit risks involved with physical activity, mental/emotional activity, cooking activity, social actvity, and engaging online, and I agree not to hold Empowerteen, 11-22 Integrative Medicine, or Dr. Paula Pilcher liable. I am aware that if I do have concerns, that it is my responsibility to have engaged contact with the appropriate parties at Empowerteen to address them. Therefore this signature will also serve as my informed consent and waiver. 

Be certain to enter your email address correctly on the registration form to receive confirmation via email.