Girl Ambassador Program Application

Fill out the form below to submit an application to the 2022 Girls For A Change Girl Ambassador Program.

Step 1 of 6 - Participant

Participant Program Information
Please tell us more about yourself in the section below.
List Middle and High School Activities*
List middle and high school activities in order of importance.
List Public Service and Community Activities*
List public service and community activities in order of importance. Do not repeat items listed previously.
List Club/Organization Activities*
List club/organization activities in order of importance. Do not repeat items listed previously.
List Awards, Scholarships, Publications, or Special Recognition*
List awards, scholarships, publications, or special recognition you have received in order of importance.
Describe your interest in STEAM, other academic area, and/or a future career*
Highlight a problem or need of society you want to address as a leader in STEAM, other academic area, and/or career setting. (If possible, use statistical data to define the magnitude of the problem.
What other personal information do you wish to share with Girls For A Change?

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Relationship to Participant*
Title (Optional)
Your Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Alt. Phone (Optional)
Email Address*

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Emergency Contact Information
Please provide contact information we should be aware of in the case of an emergency.
Relationship to Participant*
Your Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
Alt. Phone (Optional)
Employer (Optional)
Work Phone (Optional)
Additional information to know in the event of an emergency? (Optional)

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Medical Treatment & First Aid Information
Medical Treatment/First Aid Authorization*
Please check the box below to grant medical treatment/first aid authorization.
- I grant permission for the administration of First Aid to my child by the staff of Girls For A Change (GFAC), and those transporting my child to and from programs as their judgment deems advisable, and to make the necessary referrals to qualified physicians for treatment of illness or accidents of a more serious nature. I understand I will be promptly notified in the event of any serious illness or accident and prior to any major surgery, except when a delay in such communication would endanger life. In case of medical emergency, I understand that every effort will be made to contact the parent/ guardian of the participant and emergency contact. In the event that I cannot be reached, I hereby give permission to the physicians selected by the adult staff to hospitalize, secure proper treatment for, and to order injection, anesthesia or surgery, if deemed necessary for my child.
Allergies to Medications*
Please type N/A in the box below if your child is NOT allergic to any medications.
Medications Currently Taken*
Please type N/A in the box below if your child is NOT currently taking any medications.
Health Insurance Information (Optional)
Policy Holder Name
Insurance Company
Policy #
Authorized Physician Name
Authorized Physician Phone
Transportation Consent
Please tell us who will be picking up the participant from Girls For A Change?
Authorized Pickup Person Name*
First Last
Phone*
Relation to Participant*
Do you consent to field trip transportation?*
- Yes, I consent to field trip transportation.
Marketing Consent
To help us make a bigger impact, we'll be taking photography and video during Girls For A Change activities, events, and programming. We'll need your consent for us to use this content for our marketing.
Unless a letter to the contrary is received, GFAC accepts your consent for us to take photos and share them on social media as well as GFAC main website.
- I give permission to use my child’s picture on the official Girls For A Change website, social media, in newspaper advertisements, or other publications.
Release From Liability
Check the box below to release GFAC from liability.*
- I, the undersigned parent or legal guardian, release GFAC, or any other person acting on their behalf, from liability for any bodily injury sustained and loss or damage of any personal article while on the premises or participating in any activity provided by GFAC.
Rules of Conduct (must be read by Parent/Guardian AND Participant)
For Participant
You are representing yourselves, your family and community. We expect you will represent us well, and display mature and responsible behavior expected of respectable young women in society.
1. All participants are expected to demonstrate common courtesy and respect at all times. Inappropriate language/behavior will not be tolerated.
2. Participants should be modestly dressed. Writing on clothing should be respectful and positive.
3. The possession or consumption of any alcoholic beverage and/or possession/use of any illegal drug by an individual is not permitted.
4. Smoking is not permitted.
5. Weapons and/or drug paraphernalia are not allowed.
6. Prescription drugs need to be given to a staff member for storage and distribution.
7. No Eating, chewing gum or liquids are allowed in the training spaces.
8. The Girl Ambassador Program has a strict policy regarding the possession and usage of electronic devices during instructional time.
9. Participants are required to attend all scheduled Girl Ambassador meetings and training.
10. Girl Ambassador participants are allowed no more than three (3) excused or no unexcused absences during the training period. It is the participant's responsibility to notify Girls For A Change that she will be absent, by calling and emailing us.
  
  Absences may be excused for the following reasons, with appropriate documentation:
  - Doctor appointment
  - Death in the family (2 per session)
  - Religious commitment
  - Illness
  - Family Emergency IE: Car accident, hospital emergencies (1 per session)
  - Testing ( 3 per session )
  - School visit ( college tour)
  Generally, our partner will provide its employees with a handbook or workplace policies to set forth expected behavior and procedures within the workplace. All participants are expected to abide by their rules and regulations for their employees.
*Violation of these rules may lead to counseling, parental conference, or unfortunately, dismissal from the program.
For Parent/Guardian

All participants are expected to dismiss on time. A late fee of $5/minute will be assessed beginning at 5:05 p.m. If a child remains at the location beyond 30 minutes, without any form of communication to Girls For A Change staff members, we will reach out to your ER contacts listed. If an emergency arises that will delay pick up, we must be notified immediately and another person authorized to pick up your child up must come.
1. A call to the parent’s workplace and/or home.
2. A call to those authorized to pick up the child.
3. A call to the emergency contact.
4. A call to the local police department and Child Protective Services.
PICK UP BY AN INTOXICATED PARENT OR AUTHORIZED REPRESENTATIVE

CAMP DIVA will not permit parents or authorized representatives who are intoxicated to pick children up from our camp location. We do not wish to expose the location to any legal action for the improper release of children, but more importantly, we do not wish to expose the children enrolled in our programs to any danger resulting from their parents’ or authorized adult’s impaired faculties. Therefore, we will expect our staff to be alert to the possibility of parental intoxication, and if there is evidence of such intoxication by means of speech, gait, or manner, that staff member will call a second staff member to corroborate. If both staff members agree that the parent is intoxicated, the staff will not permit transportation by that person, and the Richmond Police Department will be called to assist the program staff in determining the course of action to be taken. If the parent insists on removing a child in spite of these actions, a conference will be held that week between the parent and the Director that could result in termination of the child’s participation in the program.

NON-CUSTODIAL PARENT POLICY

A parent of a child enrolled in the program who is not the child’s custodial parent will be permitted unlimited access to the camp location and be afforded the same rights as the custodial parent unless there is court documentation limiting access and contact by the non-custodial parent. This documentation must be on file in our office. Upon entering the camp location, the non-custodial parent must report to the director or designee in the child care office.

GRIEVANCE POLICY FOR PARENTS

It is the intent of the Girls For A Change programs to provide all parents and guardians with an avenue for discussing and resolving any concerns they may have with regard to the care being provided by the center. When a concern has been identified, the parent should first discuss the issue with the program staff members. It is suggested that in order to facilitate the conversation, an appointment should be scheduled and the individual requesting the appointment should prepare a written list of pertinent discussion points prior to the appointment. Notes of what was discussed and agreed to during the meeting are also encouraged. Once the staff member(s) has/have addressed the issue, based on the response, the parent or guardian should consider the issue resolved. If the staff member was unable to address the issue because of its administrative nature, or if the parent or guardian is dissatisfied with the response or outcome, he/she should then discuss the issue with the Director. At that meeting, the parent or guardian should be prepared to discuss what has transpired to-date. The Director will research the issue and respond to the parent in a follow-up meeting, or at the initial meeting if no research is needed.
Check the box below:*
- I have read the above and consent.

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GFAC Girl Ambassador Program Fees
Application Fee
Price:
Scholarship Coupon
Total
$0.00
Credit Card*
Card Details
Cardholder Name
Credit Card Billing Address*
Street Address Address Line 2 City State ZIP Code
How did you hear about Girls For A Change?*
- Social Media
- News/Newspaper
- School
- Friend/Family/Co-Worker
Receive occasional reminders via SMS/text?
Please Solve The Puzzle
Name
This field is for validation purposes and should be left unchanged.

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Girl Ambassador Program Application

Girl Ambassador Program Application

Step 1 of 6 - Participant

Participant Information

Participant Program Information

Emergency Contact Information

Medical Treatment & First Aid Information

Health Insurance Information (Optional)

Transportation Consent

Marketing Consent

Release From Liability

Rules of Conduct (must be read by Parent/Guardian AND Participant)

For Participant

For Parent/Guardian

PICK UP BY AN INTOXICATED PARENT OR AUTHORIZED REPRESENTATIVE

NON-CUSTODIAL PARENT POLICY

GRIEVANCE POLICY FOR PARENTS

GFAC Girl Ambassador Program Fees

Additional Information

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