Highland Springs High School
Immersion Lab

Girls will participate in entrepreneurial training that will culminate at the Market Day at The Oak and the opportunity to earn an entrepreneurship certificate. This program is for strictly for girls who attend Highland Springs High school.

Program dates:
Wednesdays, 4:00 pm - 6:15 pm
March 20 - June 2

Highland Springs High School
200 S Airport Dr
Highland Springs, VA 23075

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Immersion Lab at Highland Springs High School

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Step 1 of 5 - Personal

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Participants Name*

First Last

Birth Date*

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Email*

Phone*

Alt Phone

Current School*

Current Grade*

Returning Participant?*

Yes

T-Shirt Size*

Parent/Guardian Information #1

Relationship to Participant*

Title (Optional)

Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone*

Alt Phone

Email*

Parent Guardian Information #2

Relationship to participant*

Name*

First Last

Primary Phone*

Alt Phone (Optional)

Employer

Business Phone

Additional Info to know in the event of an emergency

Has your child’s school identified your child as an English Language Learner?*

Yes

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. *

Check to Grant Permission*

Allergies to Medications: Please type N/A in the boxes below if your child is not currently taking or allergic to any medications.*

Medications Currently Taking or N/A*

INSURANCE INFORMATION (OPTIONAL)

Policy Holder

Insurance Company

Policy #

Authorized Physician

Office Phone Number

Agreement Form for Transportation

Name*

First Last

Relationship to Participant*

Primary Phone*

Child will be picked up at the school/center at the end of the day*

Yes

Child will walk home alone from school/site*

Yes

Do you consent to field trip transportation?*

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.

Check to Release GFAC From Liability*

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.

Check If You Consent*

Apply for Immersion Lab Program

Consent to Disclose Student Records for Record Sharing*

This program, Functional Ceramics in partnership with Girls For A Change is funded by the City of Richmond’s Positive Youth Development and Youth Violence Program. The goal of the City of Richmond’s Positive Youth Development and Youth Violence Program is to promote positive youth development and prevent youth violence and help your child reach his or her full potential—socially, emotionally, and academically. To help the City of Richmond achieve that goal, we may need to share certain information about your child with the City of Richmond and NextUp RVA. The City of Richmond has contracted NextUp RVA to distribute funds to programs, provide technical assistance to programs and evaluate programs’ impact on youth outcomes. In turn, they may need to share certain information about your child with us. NextUp RVA is committed to ensuring all youth have a positive, quality learning experience, and sharing this information can help us better serve your child(ren). Additionally, this information will help us understand whether or not this program is having a positive impact on your child’s academic, social, and emotional well-being. Also, to improve the program and make sure it meets the needs of youth, schools, and the community, we may conduct surveys to ask questions about the kinds of programs students would like to see, what they are learning from their participation in the programs and how they view themselves as learners and how they relate to their peers and adult staff. The answers to the surveys will be used to evaluate and improve the City of Richmond’s Positive Youth Development and Youth Violence Program. By signing below, you consent to have RPS release your child’s student record to a data management system operated by a third-party partner, Cityspan Technologies (cityspan.com), and NextUp RVA. The student record has information such as your child’s attendance, grades, scores on SOL, NWEA MAP, and Imagine Learning assessments, types of services they may receive, discipline history, and demographic information. Having this information helps us better understand how our services work and how we can improve them to help your child be more successful.

Yes, I give my permission to allow RPS to disclose my child’s school records to NextUp RVA.

No, I do not give my permission to allow RPS to disclose my child’s school records to NextUp RVA.

Media Release*

Sometimes,Girls For A Change may use photos of participants in publicity and marketing materials, such as on the program’s website and social media.

Yes, I give permission to allow photos of my child to be used by Girls For A Change and NextUp RVA media and marketing materials.

No, I do not give my permission to allow photos of my child to be used by Girls For A Change and NextUp RVA.

Meal Restrictions*

I can eat anything

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Race/Ethnicity (optional)—Please describe yourself*

(check all that apply)

African American or Black

Caucasian, White Latina or Chicana

Asian or Asian American

Native Hawaiian or other Pacific Islander

Multiracial

Emergency Contact

Name

First Last

Relationship to Girl*

Cell Phone—GAT*

How did you hear about Girls For A Change*

Social Media

News/Newspaper

School

Friend/Family/Co-Worker

Other

Receive occasional reminders via SMS/text?

Please Solve The Puzzle

Name

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Highland Springs High School
Immersion Lab

Immersion Lab at Highland Springs High School

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Apply for Immersion Lab Program

Emergency Contact

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Highland Springs High School Immersion Lab

Immersion Lab at Highland Springs High School

Parent/Guardian Information #1

Parent Guardian Information #2

Apply for Immersion Lab Program

Emergency Contact

Additional Information

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Highland Springs High School
Immersion Lab