2024 GEMS Program Registration

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Please fill out all the information below.

Email *

Participant's Name (first and last name) *

Age *

Date of Birth *

YYYY

Grade *

Available Programs:

Please select the GEMS programs in which your child will participate.

Lemonade Day (3rd grade-5th grade girls only)

5G-Girls Growth Mindset Camp (5th grade girls only)

Picking up STEAM Tour (5th grade-12th girls only)

Etiquette-Netiquette (5th grade -11th grade girls only)

Self Care Saturday (5th grade-11th grade girls only)

Pop Up Shop (5th grade-11th grade girls only)

Pajama Power (5th grade-11th grade girls only)

Not a Number(7th grade-12th grade girls only)

Shining Gems-Community Service and Sisterhood (3rd grade-12th grade girls only)

Required

School *

T-shirt Size *

Girl's Email Address

Girl's Phone Number

Parent/Guardian's Name *

Address *

City *

State *

Zip Code *

Parent/Guardian Email Address *

Parent/Guardian's Phone Number *

To help us keep these programs available, Girls Empowered for More Society, Inc. must raise funds from a variety of donors. Please help us in this effort by answering the following questions. This information will only be shared as an aggregate number (i.e. 50% of girls...) and will NOT affect your daughter’s participation in the program.

What is the ethnicity/race of the girl participating (check all that apply): *

Alaskan Native/Native American

African American/Black

Asian

Caucasian/White

Hawaiian/Pacific Islander

Latino/Hispanic

Other:

Required

What language(s) is spoken in your home?
*

English

Spanish

Other:

Required

Who lives with the participant at home? Please check one only.
*

Both Parents

Mother Only

Father Only

Only one parent at a time (Joint Custody)

Neither Parent

Other:

Required

Is the Head of Household a female?
*

Yes

Required

How many people are in the household?
*

Is someone in the household currently receiving: (check all that apply)
*

Food Stamps

TANF

Medicaid

SSDI

SSI

Free/reduced lunch

None of these

Required

Please provide your income level:
*

$0-10,000

$10,001-20,000

$20,001-30,000

$30,001-50, 000

Over $50,000

Required

Has the participant been involved in the juvenile justice system? *

Yes

I, the undersigned, certify that the information shown above is true and accurate to the best of my knowledge. I understand that I may be subject to criminal prosecution for knowingly providing false information to the agency.
*

I agree.

Required

I agree to provide Girls Empowered for More Society, Inc. with my girls’ school information which includes academic, attendance, and behavior records, if requested.
*

I agree.

Required

I give permission for my child to be photographed and for those pictures or materials she creates to be used for marketing purposes of Girls Empowered for More Society, Inc. and their partners. I hereby waive any right to inspect or approve photographs, video, or recordings made in conjunction with participation. I hereby release, discharge, and save Girls Empowered for More Society, Inc. from any liability from the use of this material.
*

Yes

Required

I give permission for my child to participate in evaluations as part of Girls Empowered for More Society, Inc. programs including pre-and post-program surveys.
*

Yes

Required

If your child requires special accommodations, please provide specific details.

It is our goal to create an inclusive and supportive environment for all girls, including those with special needs. To ensure this, we will provide reasonable accommodations for girls with special needs during our events. We encourage parents to communicate any specific needs or requirements a girl may have. This will help us better understand how we can support them and create a positive experience for everyone involved. If your child requires any modifications to our facilities or equipment, please let us know in advance. If your child requires additional assistance or support during our activities, we will make efforts to assign a volunteer to assist them. However, there may be instances where a capable volunteer is not available. In such cases, parents or a designated caregiver must accompany your child during the activity to provide the necessary support.
*

I understand.

Required

Parent/Guardian's Name *

Date *

YYYY

Signature *

If you have further questions or concerns about the program, please feel free to contact Toccara Huckaby at 318-800-8584 or gems4value@gmail.com.

Girls Empowered for More Society, Inc. would like to stay in contact with you and your child for the purposes of involving you in future programming opportunities-including special field trips, workshops, and future programs. In addition, we hope to stay in touch to share how Girls Empowered for More Society, Inc. girls thrive and achieve in the future!

The information you provide will not be used by anyone outside of Girls Empowered for More Society, Inc.

A copy of your responses will be emailed to the address you provided.

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