2025 Middle School Summer Retreat Form

Middle School Summer Retreat

July 28-August 1, 2025
Hello Guardian!

Dr. Paula Pilcher, ND, is so excited to share her teen empowerment program with your teen 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 teen'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.

LOCATION: Scholls Valley Lodge, 12840 SW River Rd, Beaverton OR

WE MEET: Please drop your teen off at Scholls Valley Lodge 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. If you need arrangements made for your teen to be dropped off earlier or picked up later, contact us to work this out.

We will send out an information sheet the week before the retreat commences to remind you of the details, directions, and needs for your teen.

Your teen will look forward to the fun and variety of each day, while making new friends, bonding with their high school 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:

events@empowerteen.org or give us a call at 503-207-6284

For anything you need Dr. Paula to know specifically about your teen'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.
Teen Participant's Information
First Name*
Middle Name
Last Name*
Nickname
Gender*

MaleFemaleOther
Preferred Pronouns*

She / Her / HersHe / Him / HisThey / Them / TheirsOther
Birth Date*

MonthDayYear
Grade of school entering in the fall (or equivalent)*
Teen Participant's Contact
Teen's Email (for sending/receiving lesson-related items and polls during retreat)*
example@example.com
Teen's Phone (for contacting if needed during retreat)*

Area CodePhone Number
Address*
City*
State*
Zip*
School attending in the fall 0f 2024 (name of school, city, state)
Parent or Legal Guardian Information
Parent /Legal Guardian 1*

First NameLast Name
Relation*
Cell Phone*

Area CodePhone Number
Work Phone*

Area CodePhone Number
Guardian's Email (retreat confirmation and announcements will be sent by email)*
Parent /Legal Guardian 2

First NameLast Name
Relation 2
Cell Phone 2

Area CodePhone Number
Work Phone 2

Area CodePhone Number
2nd Guardian's Email
Who has legal custody over the teen participant?*
Emergency Contact (OTHER THAN GUARDIANS)

We will reach out to this contact only after trying above-listed guardians
Emergency Contact Name (other than guardian)*
How does teen know this contact?*
Emergency Contact Number (other than guardian)*

Area CodePhone Number
Emergency Number #2 (if available)

Area CodePhone Number
We're so glad you found us!
How did you find out about Empowerteen?*

Online Search Engine (Google, Bing, Yahoo, etc.)Tualatin Hills Parks and Recreation DistrictSchool District or SchoolVision Board Party GuestFacebook PostFacebook GroupInstagramPostcard MailerFrom someone who previously attendedReferralOther
If you were referred to Empowerteen, by whom were you referred?
Has your teen attended an Empowerteen event before, or are you new to Empowerteen? (events include retreats, classes, workshops, field trips, fundraisers and socials)

Yep, they've attended at least 1 Empowerteen event in the past.Yep, they've attended 2-3 Empowerteen events in the past.Yep, they've attended 4 or more Empowerteen events in the past.Nope, they're new but have a friend or relative who has attended in the past.Nope, they're brand new and don't know anyone who has ever attended.
Checklist For Participants:

make sure they have what they need!
- ___ 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
Permissions Form
We will be around gardens with bees, flowers, insects, pollens, grasses, and other outdoor allergens. Does your teen have any allergies or need any medications related to this? (ie., Benadryl, Asthma Inhaler, Anti-Histamine, Epi Pen, etc.)*

YesNoOther
We will be doing activities and exercises that include stretching, strengthening, and vigorous movement. Does your teen have any physical restrictions related to this? (ie., injuries, scoliosis, pinched nerve, blood sugar or blood pressure concerns, etc.)*

YesNoOther
We will be outside during most of each day. Does your teen have any restrictions regarding this? (ie., direct sun, skin exposure, heat intolerance, sitting on wool blanket, etc.)*

YesNoOther
We will be doing DIY labs. Does your teen have any allergies to ingredients or topical skin items related to this? (ie., nuts and coconut oils, beeswax, shea butter, honey, essential oils, flowers, etc.)*

YesNoOther
We will be doing a cooking lab. Does your teen have any allergies or intolerances to foods or food ingredients related to this? (ie., nuts, gluten, dairy, shellfish, soy, wheat, etc.) Do they have any dietary restrictions or needs (ie., vegetarian, vegan, pescatarian, kosher, religious requirements, etc.)?*

YesNoOther
We will be sending out a survey to the teens to find out what foods they like/dislike and what they're interested in learning how to make in order to put together the menu for the Cooking Lab. To what email would you like us to send this survey in order for it to be filled out in a timely manner? (maybe it's you, if your teen is known to not check email often or respond in a timely manner)*
Type email to send survey to
All fields are required below. If nothing applies, please put "NONE" in the box. Thanks!
Does your teen have any special needs or accessibility requirements that we should know about? If so, please list how we may assist during the summer retreat.*
Is there any activity or lesson topic your teen should be restricted from?*
Is there any physical, mental or other condition now or in the past that would require special attention, consideration, or medication while at the summer retreat?*
List any past medical treatment that would be helpful for us to know (this includes physical as well as mental-emotional or treatment for trauma).*
What would you like Dr. Paula to know that will help to facilitate your teen's experience at the summer retreat in the best way possible?*
What are you hoping your teen will get out of this summer retreat experience?*
Has your teen received a vaccine for the COVID-19 virus?

YesNoPartialOther
Health and Emergencies Policy
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 teen 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 teen 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.
Teen Participant Release Form

please read and sign below...
By pressing 'submit' and signing this form, I agree that I am the parent or legal guardian of the above named teen 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 teen participant by authorized personnel. I understand that the above named teen participant will only be discussed with the names listed above and the teen themself regarding information pertinent to this retreat. I understand that it is my responsibility to notify Dr. Paula if my teen is experiencing symptoms such as fever over 99 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 teen 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 teen'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 teen 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 teen'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 21st, 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.
I Agree with the Teen Participant Release statements above (Signature in box below)*

Clear
Signature is manually required above.
Be certain to enter your email address correctly on the registration form to receive confirmation via email.
Should be Empty:

Middle School Summer Retreat

Teen Participant's Information

Teen Participant's Contact

Parent or Legal Guardian Information

Emergency Contact (OTHER THAN GUARDIANS)

We're so glad you found us!

Checklist For Participants:

Permissions Form

Health and Emergencies Policy

Teen Participant Release Form