EmpowerU - Enrollment Form (Parent)

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Email *

There are 2 steps to enroll in EmpowerU.

You are enrolling in the semester course of Empoweru - it is 12-14 weeks and your student is agreeing to complete one lesson each weekday (20-30 minutes). The fee is $375/student.

Who is the parent/guardian of the student? *

What is the EmpowerU student's name? *

Important Student Contact Information

What is your teen's preferred email address to use for this course? (please be exact- this is how we will communicate with your teen) *

What is your relationship to the student? *

What does your teen identify as for the following: Race, Ethnicity, Gender, Religious preference?

What is your teen's cell phone number? *

What year in school will your teen be in Fall 2019? *

Where does your teen attend school? What is his/her counselor/advisor's email address? ( we need this information if your student wants to possibly receive credit.) If you would rather we not contact the school, please let us know but then your student waives the right to the chance to possibly receive elective discretionary credit. *

Information that will help us personalize EmpowerU to your teen's struggles and stressors.

Is your teen on an IEP or 504 plan? Or does your teen have any other accommodations we should know about? *

Does your teen have any diagnoses that would be helpful for us to know about? *

Where do you think your teen needs to make improvements (i.e. academics, personal wellness, social, emotional wellness)? What are your teen's current greatest struggles? *

What have you tried at home to help your teen that has been helpful or not helpful?

Select all that apply related to your teen's stress management. *

Utilizes healthy stress management strategies (e.g. exercise, yoga, meditation, journaling, counseling)

Utilizes unhealthy stress management strategies (e.g. eating unhealthy foods, caffeine, drugs/alcohol, unhealthy relationships)

High level of stress on average

Moderate level of stress on average

Low level of stress on average

Does not understand how to manage his/her stress.

Other:

Required

Which of the following are you concerned about for your teen? *

Anixety/Stress level

Low mood/despression

Motivation/perserverence

Digital footprint and choices with phone

Amount of technology usage

Attention/Focus

Alcohol use

Tobacco use

Recreational Drugs including marijanna

Anger/definance

Required

Anything else you would like us to know that might help us personalize our feedback and teaching with your teen? *

Please select "I agree" below to allow us to talk with your teen's school if necessary. I agree to allow EmpowerU to discuss my child's progress with his/her school counselor or designated EmpowerU school contact as needed, including grades, attendance, school progress/health. Any released information will be held confidential between parties and used solely for the purposes of student goal setting and success in the EmpowerU course. Type "I agree" below as official release. (for more on EmpowerU privacy policy, check our website at empoweru.education) *

I agree

Required

Thank you so much! Please click submit. You should receive an email with a link to pay the course fee shortly. You will not be fully registered until payment is received. Please email ginny@empoweru.education with questions, or write your questions below.

THANK YOU! WE LOOK FORWARD TO GETTING TO KNOW YOUR TEEN!

https://empoweru.education

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