Girls Leading Our World Fall Registration Form

Girls Leading Our World
2025-2026 Academic Year

Parent/Guardian Consent Form

We are excited that your daughter is interested in joining the Girls Lead Our World (GLOW) Program! Your permission is needed for your child's general participation in the GLOW Mentoring Program and the release of information for your child's grades, attendance, and behavior. Please complete and submit this form for your child's participation in the program.

CONSENT TO PARTICIPATE: I consent for my daughter, to participate in the GLOW mentoring program sponsored by Durhams Hope For Kids. GLOW meets in person weekly or bi-weekly for 60-90 minutes. I am aware that Durhams Hope For Kids is a local 501(c)(3) nonprofit organization that offers mentoring programs for girls and participation involves meetings, group outings and community service. I agree to hold harmless Durhams Hope For Kids against any liability, loss or expense incurred or suffered in consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct and execution of the GLOW mentoring program. I understand that my child may engage in discussions pertaining to drugs, alcohol, sexual behavior, dating, violence and other sensitive topics. I understand that my daughter will participate in the program from Fall 2025 to Spring 2026.
VIRTUAL MENTORING: On occasion, we will host virtual experiences. Please provide permission for your daughter to participate in virtual group mentoring with the Girls Leading Our World Program. I understand that the organization has taken measures to ensure a safe interaction(s) with her mentors such as interviewing, training, and comprehensive background checks.
Parent initial below.*
RELEASE OF SCHOOL RECORDS/INFORMATION: I, the undersigned, consent to Durhams Hope For Kids and their GLOW program and evaluation staff to have access to my daughter’s school records. I agree to allow my daughter’s school to release their school records including grades, attendance and discipline records for the purpose of research and presenting impact data. I understand that my daughter will complete a confidential survey about her attitudes and opinions about the program as part of an evaluation. I understand that the information provided by the school and my daughter will be statistically analyzed and that my daughter’s name will be withheld for confidentiality purposes. I understand that this information, in addition to the survey, will be a component of the larger evaluation process and only the program and evaluation staff will have access to the confidential information.

TRANSPORTATION: When possible and if necessary, I, the undersigned, hereby grant permission for the GLOW program staff/volunteers to transport my daughter to and from various activities and hold harmless Durhams Hope For Kids against any liability, loss or expense incurred or suffered in consequence of any action or actions, suit or suits, in law or equity, which may be brought by any person or persons in connection with, or with reference to, the administration, planning, preparation, development, conduct and execution of the GLOW mentoring program. Parents will be notified in advance if transportation will not be provided to an outing or event. Parents will then be responsible to secure transportation for their daughter to participate in an event or outing.

PHOTO RELEASE: I, the undersigned, hereby grant permission to Durhams Hope For Kids to take and reproduce photographs for publication, including publication by news sources and other sources for all educational, trade, advertising and other purposes as determined by the GLOW Program. These images may be used for GLOW displays, brochures, newsletters, archives, news releases, publicity, social media and Websites.

Mentee must agree to participate in the Girls Leading Our World (GLOW) Mentoring Program and agree to: Participate in outings, field trips, community service projects and GLOW Events. Communicate with my mentor and/or Program Facilitator if I feel uncomfortable or experience problems during the program. Abide by the rules and regulations of the Girls Leading Our World Mentoring Program.
Section l: Parent/Guardian Information
Name of Parent/Guardian*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Part II: Emergency Contact Information
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone*
Please enter a valid phone number.
Part III: Daughter/Mentee Information
Daugher/Mentee Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Please select daughters ethnicity (Hispanic or Latino, or Not Hispanic or Latino)

Hispanic or LatinoNot Hispanic or Latino
Please select daughters race

American Indian or Alaskan NativeAsian / Pacific IslanderBlack or African American.HispanicWhite / CaucasianOther
Daughter/Mentee School Name*
Grade*
Daughter/Mentee Lives With*

MotherFatherStep-MotherStep-FatherGrandmotherGrandfatherFoster ParentGuardianOther
Daughter/Mentee T-shirt size*
Part IV: Parent/Guardian Additional Information & Signature
What is your relation to the Mentee?*
What three words would you use to best describe your daughter?*
What type of changes would you like to see in your daughter after participation in GLOW?*
Is there any additional information you would like us to know about your daughter that will be helpful in mentoring her?*
By signing/printing your name below, you have read and completed the above consent form and are providing consent for your daughter to participate in the GLOW Program.
Signature of Parent/Guardian*

Powered by Jotform SignClear
My Products*
prevnext( X )
GLOW One Time Fall '25 Dues
$50.00 Quantity

Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty: