Program of Interest
*
Cupcakes - Ages 4 - 11
Mentees – Ages 12-19
Name of Parent/Guardian/Primary Contact
*Please skip this section if you are 18 years or older*
First Name
Last Name
Email
Address
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Phone
(###)
###
####
Best way to contact you?
Home Phone
Cell Phone
Email
I understand that as a parent that there are times you all will need my participation. I am willing to participate as a volunteer, assist with fundraising, and join the parent's group. I will love to show up and be active in my community with my daughter and an awesome organization.
Yes
No
Participant 's Name
*
First Name
Last Name
Name you to prefer to be called (if different):
Age
Date of Birth
*
MM
DD
YYYY
Grade
*
Name of School/College
*
If the participant is not currently a college student, what college(s) do they desire to attend?
Please check here if the participant is undecided about future career choices.
Undecided
Extra-Curricular Activities:
Please list your hobbies, recreation interests, talents, skills, community groups/clubs, career/professional aspirations/dream:
T-shirt Size Type:
*
Child
Youth
Adult
How many additional program shirts/sizes would you like to order?
$15.00 for youth shirts and $20.00 for adult shirts. (Please add a $1 to each size after XL)
What do you believe are the participant’s personal challenge(s)?
Ex. Shy, Confidence, Experiencing Bullying, Career Exploration, Self-Esteem, Etc.
What Specific Areas/Topics do you think would be beneficial to your participant's growth and development?
Ex. Self Esteem, Etiquette, Budgeting, Bullying, College Preparation,Starting A Business, Etc.
Are you on Facebook?
Yes
No
If you are not on social media, how would you like to be contacted for youth programs communications. (ex. email, text, etc.)
Is there anything else you would like us to know?
Emergency Contact #1 (Name, Phone #, Email and Relation To Child)
*
Emergency Contact #2 (Name, Phone #, Email and Relation To Child)
Agreement to Electronic Consent
*
All scheduled events in person are canceled and now virtual due to COVID-19 until the Fall of 2021. My Child/ren photos and quotes may be used for publicity purposes. I understand and agree that all photos/videos will become the property of the Beautiful Spirited Women and will not be returned. I hereby grant Beautiful Spirited Women permission to use our likeness in a photograph, video presentations, website, newspapers, or other digital media (“photo”) in any and all of its publications, including web-based publications anytime, without compensation from the organization or other consideration.
YES
NO
Insurance Policy #
*
Name of Health Insurance
*
Provider
*
Primacy Physician (Name, Address and Phone #)
*
Hospital Preference
*
Please list any medical concerns, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures). List: Medical Problem | Required Treatment | Should Paramedic be called?
*
Please list any medical concerns, including any requiring maintenance medication (i.e. Diabetic, Asthma, Seizures). List: Medical Problem | Required Treatment | Should Paramedic be called?
Is your child presently being treated for an injury or sickness, or taking any form of medication for any reason?
YES
NO
Is your child allergic to any type of food or medication?
Do you agree that the provided information provided is correct and give electronic consent to the BSW Medical Form?
*
YES
NO