One World Girl Be A Changemaker! Summer Empowerment Program

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REGISTRATION FORM

For Girls, ages 8-12

Monday, July 8 - Friday, July 12, 2024
10:00am - 3:00pm daily

In partnership with and located at

Juan Pablo Duarte Foundation
(inside GWB bus terminal)
408 Ft. Washington Ave, Suite 23A
Questions: laura@jpdfoundation.org

Registration is accepted on a first-come, first-served basis, space is limited to 25 participants, so register today. For more information, please contact info.oneworldgirl@gmail.com.

After completing the registration form, you will receive confirmation within 5 days of submission.

Email *

Record my email address with my response

Child's Name *

Birthdate *

YYYY

Age *

Grade *

School *

Parent/Guardian Information

Parent(s)/Legal Guardian(s) Name(s) *

Street Address *

City *

State *

Zip code *

Home phone (put n/a if none) *

Cell Phone (put n/a if none) *

Work phone (put n/a if none) *

Email *

Emergency Contact Number *

Alternative Contact person in case of emergency *

Alternative contact person phone number *

Insurance Information

Medical coverage for child? *

Yes

Insurance Company *

Policy Number *

Family Physician *

Physician's Phone Number *

Allergies including food or medical problems/conditions *

Special instructions for handling allergies or medical problems/conditions *

By signing below, I confirm that all of the above information is accurate and that I am the parent/legal guardian of the applicant listed above. (Type initials below) *

I confirm that my child will attend and be available for all of the activities, workshops and classes at the One World Girl "OWG" summer empowerment program at the location and date provided in this registration form. (Type initials below) *

I agree to make sure that my child is feeling healthy and fever-free each day that she comes to the OWG summer empowerment program and will keep her at home if she is not feeling well, notifying the program director. (Initial below) *

I understand that the OWG summer empowerment program involves theater arts activities, art making and various interactive group learning activities. I release One World Girl, Inc., its partner organizations, and all staff, workshop guests, teaching assistants, adult chaperones and volunteer drivers from responsibility for injury, or illness to my child, or theft of my child’s personal property during the program. (Typing your name below will count as an electronic signature of this application.) *

I hereby authorize One World Girl to publish the photographs taken at the OWG summer empowerment program of my child for public relations purposes, including but not limited to printed material, local newspapers, video or websites. I release OWG from any expectation of confidentiality with respect to the photographed images of my child and acknowledge that since participation in any of the aforementioned publications and websites produced by OWG is voluntary, neither my child nor I will receive financial compensation. I further agree that participation in any publication and website produced by OWG confers no rights of ownership to me whatsoever. (Typing your name below will count as an electronic signature of this application.)

Finally, signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the OWG summer empowerment program and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the OWG summer empowerment program may result from the actions, omissions, or negligence of the Company and others, including, but not limited to, Company’s employees, volunteers, partner organizations and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the OWG summer empowerment program or participation in any related programming (“Claims”). On my behalf, and on behalf of my child(ren), I hereby release, covenant not to sue, discharge, and hold harmless the Company, its employees, agents, representatives and partner organizations, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the Company, its employees, agents, representatives and partner organizations, whether a COVID-19 infection occurs before, during, or after participation in any program for the OWG summer empowerment program. (Typing your name below will count as an electronic signature of this application.)

Date of signature *

YYYY

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