Pathways to Success - Registration
Pathways To Success - Program Registration
The Pathways to Success Program is a 10-week curriculum-based youth leadership program where trained facilitators cover topics such as character education, integrity and self-control, emotional and mental health, discovering assets, strengths assessment, and job readiness training. Students also receive public speaking training, qualifying them for certification through Toastmasters International.
Caminos Hacia El Éxito
"Caminos Hacia El éxito” es un programa de liderazgo juvenil que guiará a los estudiantes a través de un probado plan de estudios, cubriendo la educación del carácter, valoración de los puntos fuertes del estudiante y formación de preparación para el trabajo. Los estudiantes del programa reciben formación para hablar en público y oportunidades de practicar y mejorar su manera de presentarse, lo cual les permite sacar el título de Toastmasters International.
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English
Español
Parent/Guardian Registration Form.
Please answer all questions as clearly as possible.
Parent/Guardian Name:
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Email
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example@example.com
Student/Minor Name:
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Parent/Guardian's Mobile Phone Number:
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Please enter a valid phone number.
I consent to receive periodic text messages from a 3rd party texting service at the above mobile number containing important updates and information from Four Corners Group about events, programming, opportunities, and more. If at any time I wish to unsubscribe, I can notify Four Corners Group.
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I agree
I do not agree
Parent/Guardian's Home Address:
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Parent/Guardian presence and involvement in home:
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1
2
Co-parent different homes
Foster Child
Adoptive Child
Check ALL issues/concerns for youth:
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Alcohol/Smoking
Drug Use (prescription/illegal)
High Risk Behavior
Alternative School
Youth Detention Center/ RYDC
Court Involved
Briefly describe your current family and living situation.
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Student's current school:
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Student's current grade level (select below):
Please Select
6th
7th
8th
9th
10th
11th
12th
None
Student's birthday:
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-
Month
-
Day
Year
Date Picker Icon
Student's Gender:
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Please Select
Male
Female
Non-binary
Transgender
Student's phone number (if applicable):
Please enter a valid phone number.
Please list any hobbies, sports or positive activities the youth is active or interested in.
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Which campus does your student plan to attend?
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Marietta Campus: Walton Ridenour "Commons" Building, 1425 Ridenour Blvd, Kennesaw, GA
Austell Campus: 6130 Hotel St, Austell, GA
How were you referred to or hear about Pathways to Success?
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School Social Worker/School
Department of Juvenile Justice (DJJ and/or Youth Detention Center)
Juvenile Courts
Website
Community Member
Other
Are you a part of a Walton Community?
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Yes
No
If Yes, which community?
Walton Ridenour
Walton Village
Walton Reserve
Other
Permission And Signature
Please read and sign the following general waiver and consent.
As a parent or guardian, I understand that activities sponsored by Four Corners Group (FCG) are not in any way affiliated with Cobb County School System, Communities in Schools, MUST Ministries, Passion For Life, Open Door Talk, Storehouse Ministries, Safe House or any of the community partners FCG services. I, hereby give my full consent and approval for the above mentioned youth registrant to participate in all Four Corners Group “Pathways” activities, and be transported in commercial transportation designated by the members of the FCG/Pathways team to attend activities related to or sponsored by Four Corners Group. I hereby waive, release and hold harmless Four Corners Group, FCG Pathways team members, sponsors, representatives and affiliates for any injury or illness that may be suffered by my child in the normal course of participation in scheduled activities, whether the result of negligence or any other cause. In addition, I authorize transportation coordinators to act for me according to their best judgment in any emergency requiring medical attention. I understand that should an emergency arise, I and/or the person listed below will be contacted immediately.
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I give permission for my youth to be videotaped and/or photographed while participating in any FCG Pathways program with the intention of the videotape or photograph appearing in FCG Pathways promotional materials, advertisements, social media and/or newsletter. The videotape or photograph will be used for no other purpose than those stated above. I also agree to periodically provide insights to Four Corners Group about how my youth is doing through surveys, phone calls, etc.
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Yes
No
Emergency Contact Name:
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Emergency Contact Phone Number:
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Please enter a valid phone number.
Additional comments and concerns that were not covered in the above questionnaire.
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Cuestionario de arriba (Español)
Dirección de correo electrónico (email)/Su email
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Nombre del joven
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Nombre de los padres / tutor legal
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Número de teléfono de los padres / tutor legal
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Please enter a valid phone number.
Consiento en recibir mensajes de texto periódicos al número de arriba de un servicio de terceras partes en cuanto a novedades e información sobre los eventos, los programas y las oportunidades de la organización Four Corners Group. Si en algún momento deseo darme de baja, puedo notificarle a la organización Four Corners Group.
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Estoy de acuerdo
No estoy de acuerdo
Dirección
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Padres que están involucrados en la vida del joven:
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1
2
Los dos están involucrados, pero viven en casas diferentes
Niño en adopción temporal
Seleccione la conducta problemática: que está exhibiendo el/la estudiante:
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El/la estudiante está tomando alcohol o fumando
Uso de drogas o de medicamento con receta
Comportamiento de alto riesgo
El/la estudiante está inscrito en un colegio para adolescentes que requieren una atención diferenciada
El/la estudiante está en un centro de detención juvenil
El/la estudiante ha tenido que ir ante un tribunal por su comportamiento
Por favor, explique brevemente su actual situación familiar.
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Escuela actual del estudiante
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Grado actual del estudiante (7th, 8th, etc
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Fecha de nacimiento del estudiante
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-
Month
-
Day
Year
Date Picker Icon
Número de teléfono del estudiante
Please enter a valid phone number.
Por favor, haga una lista de pasatiempos, deportes u otras actividades positivas que le interesan al joven.
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¿A qué centro piensa asistir su estudiante?
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Marietta Campus: Walton Ridenour "Commons" Building, 1425 Ridenour Blvd, Kennesaw, GA
Austell Campus: Sweetwater Mission, 6130 Hotel St, Austell, GA
¿Cómo te refirieron a esta programa?
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Escuela
Comunidad
Department of Juvenile Justice (DJJ or Youth Detention Center)
Juvenile Courts
Other
Como padre/tutor legal, entiendo que las actividades patrocinadas por la organización Four Corners Group (FCG) no son en absoluto afiliadas ni con el sistema escolar del condado de Cobb ni con las organizaciones Communities in Schools, MUST Ministries, Storehouse Ministries, Safe House ni ningún socio de la comunidad con lo cual trabaja en conjunto la organización FCG.Por medio del presente yo doy mi permiso completo y autorizo a mi hijo(a) a participar en todas las actividades del programa “Caminos hacia el éxito” de la organización Four Corners Group y a ser transportado a actividades relacionadas con o patrocinadas por FCG en vehículos comerciales indicados por los miembros de FCG. Por medio del presente, renuncio a toda la responsabilidad legal de la organización FCG, de sus miembros, de sus patrocinadores, de sus representantes y de sus afiliados de cualquier herida o enfermedad que sufra mi hijo(a) al participar en el curso normal de las actividades programadas, sean consecuencias de la negligencia o de cualquier otra causa. Además, si surge una emergencia en la cual se requiere atención médica inmediata, autorizo a los coordinadores de transporte a actuar de mi parte según su propio juicio. En este caso, entiendo que nos informarán enseguida a mí y a la persona enumerada a continuación.
Doy permiso para que mi hijo sea grabado en video y/o fotografiado mientras participa en cualquier programa de FCG Pathways con la intención de que la cinta de video o la fotografía aparezcan en materiales promocionales, anuncios, redes sociales y/o boletines informativos de FCG Pathways. La cinta de vídeo o la fotografía no se utilizarán para ningún otro fin que los indicados anteriormente.
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Sí
No
Nombre de contacto de emergencia:
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Telefono de contacto de emergencia:
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Please enter a valid phone number.
Comentarios/preocupaciones adicionales que no se mencionan en el cuestionario de arriba:
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If you are ready to pay the $75 Registration Fee, click/tap here:
Registration Fee Payment
Registration fee for the Pathways to Success Program is $75 per student. This fee includes the student's involvement in our programming opportunities for one year. The student will receive a scholarship for the rest of the program cost thanks to generous grants, donors, and sponsors. This fee is non-refundable, and is due upon the first week of the 10-week program. Payment details will be sent upon completion of this registration. Should this fee be prohibitive in any way for the student to join the program, please complete this form and then contact Janet Porter, Program Director, to discuss options (payment plan, scholarship, etc).
PayPal payment below (card, Venmo). To send via CashApp, send $75 to $FourCornersGroupInc
Please include student name in payment.
Program Registration Fee
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Registration Fee
One Year registration fee for Four Corners Group youth programming
$
75.00
Payment Methods
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