Girls RAP Participation Information Form

Register for Girls RAP

Girls RAP is an empowerment program that supports girls ages 12-18 with navigating girlhood and building healthy relationships.

Fill out the form below to register for Girls RAP. Questions? Contact DaVonna Rucker at drucker@ywcampls.org or 612-215-4123

Return to Girls RAP Complete Permission Form

Girls RAP Participation Information Form

Step 1 of 2

Youth Information
Name*
First Last
Address*
Street Address Address Line 2 City State ZIP Code
Phone*
School*
Student ID
Date of Birth*
Grade*
Select the YWCA program you are registering for:*
Free/Reduced Lunch Program Eligibility*
Race/Ethnicity
Tribal Affiliation
If you selected American Indian/Native American/Indigenous in the question above, please let us know the name of the tribe you are affiliated with.
Biological Sex*
Gender Identity
List any special medical conditions/allergies/dietary restrictions:
T-Shirt Size:

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Family Information
Youth lives with:*
Parent/Guardian Name*
First Last
Phone*
Email*
Relationship to Applicant*
Parent/Guardian Consent
I hereby permit my child to participate in all activates of the Girls RAP program. I hereby certify that my child, to my knowledge, is capable of participating safely in the educational, athletic and recreational programs of Girls RAP. I understand the arrangements and believe the necessary precautions and plans for the care and supervision of my child during the programming will be taken. Beyond what is outlined in the other sections, YWCA staff or program staff will not be liable for occurrences in the groups. 1. I grant permission for my child/ward: - To participate in all activities of YWCA youth programs - To participate in program field trips under proper supervision - To ride in authorized YWCA vehicles for program activities - For the YWCA Youth Program Counselor to obtain information on my child’s/ward’s academic and attendance records 2. I understand that programs may contain information on sexuality and other health-related issues and I give my child/ward permission to participate. 3. I agree that neither YWCA nor any other person associated with them has any responsibility to me or to my child/ward for any claims arising from accident, health or medical treatment. 4. I understand that any expenses incurred under item 3 will be the sole responsibility of the child’s/ward’s family. 5. I understand that YWCA staff and volunteers are Mandated Reporters. If abuse or neglect is suspected, YWCA staff and volunteers are required by Minnesota law and YWCA policies to place a report to Child Protection Services. 6. I will NOT hold YWCA Minneapolis responsible for any personal property that is lost or stolen during participation. 7. Should any injury occur to my child during participation in said program, I authorize Girls RAP to arrange for or provide emergency medical treatment and arrange for or provide transportation to the nearest qualified medical facility. 8. I grant permission for medical personnel to act as judgement dictates, in case emergency care is needed for my child.*
I agree to the following statements:
I hereby permit my child to participate in all activates of the Girls RAP program. I hereby certify that my child, to my knowledge, is capable of participating safely in the educational, athletic and recreational programs of Girls RAP. I understand the arrangements and believe the necessary precautions and plans for the care and supervision of my child during the programming will be taken. Beyond what is outlined in the other sections, YWCA staff or program staff will not be liable for occurrences in the groups.

1. I grant permission for my child/ward:
- To participate in all activities of YWCA youth programs
- To participate in program field trips under proper supervision
- To ride in authorized YWCA vehicles for program activities
- For the YWCA Youth Program Counselor to obtain information on my child’s/ward’s academic and attendance records

2. I understand that programs may contain information on sexuality and other health-related issues and I give my
child/ward permission to participate.

3. I agree that neither YWCA nor any other person associated with them has any responsibility to me or to my
child/ward for any claims arising from accident, health or medical treatment.

4. I understand that any expenses incurred under item 3 will be the sole responsibility of the child’s/ward’s family.

5. I understand that YWCA staff and volunteers are Mandated Reporters. If abuse or neglect is suspected, YWCA staff
and volunteers are required by Minnesota law and YWCA policies to place a report to Child Protection Services.

6. I will NOT hold YWCA Minneapolis responsible for any personal property that is lost or stolen during participation.

7. Should any injury occur to my child during participation in said program, I authorize Girls RAP to arrange for or provide emergency medical treatment and arrange for or provide transportation to the nearest qualified medical facility.

8. I grant permission for medical personnel to act as judgement dictates, in case emergency care is needed for my child.
Parent/Guardian Signature*
By typing my full name in the box below, I consent to the above. This is equivalent to my signature.
Publicity Consent
- Make video and audio recordings of me and/or my voice. - Take and use photographs of me and/or my family. - Record, use, display and disclose in a video and/or other media intended for public consumption statements and/or information provided by me concerning myself and/or my family. - Use the activities listed above for direct mail, advertising, public relations, website, email, social media (e.g., Facebook, Twitter, etc.) and other online efforts related to the YWCA of Minneapolis. - Use my name and the names of members of my family in conjunction with the activities listed above. With respect to the above, I relinquish to the YWCA of Minneapolis all rights, title and interest I may have in all originals, edited versions, reproductions, and copies of any video and/or audio recording(s), prints, negatives, digital images and photographs in which my or members my family’s name, image, statements, information, and/or voice is used (the “Materials”). I also irrevocably grant the YWCA of Minneapolis permission to copyright, if applicable, the Materials, and to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the Materials in any manner and for any reason the YWCA of Minneapolis may deem proper, including the right to use the same for purposes of advertising or trade. By signing this Publicity Consent Release, I acknowledge that the YWCA of Minneapolis is not responsible for the unauthorized use of the Materials by unrelated third parties. I hereby release the YWCA of Minneapolis from liability for any damages that may arise from the unauthorized use of the Materials by a third party. NOTE: If you should no longer like the YWCA of Minneapolis to use your image in its awareness and education materials and activities, please contact the YWCA of Minneapolis. Due to the distribution and printing timelines, some of the materials the YWCA of Minneapolis may not be able to remove your image immediately from its pieces, but will do so as soon as those print pieces are scheduled for reprinting or new production. Print materials that are distributed to public audiences may not be recalled once distributed. Materials used for emails, website, social media or other online efforts may be removed from YWCA sites and networks, but due to the nature of the internet, may remain available online through other sources indefinitely.
I hereby grant voluntarily and without monetary compensation the YWCA of Minneapolis permission to:
- Make video and audio recordings of me and/or my voice.
- Take and use photographs of me and/or my family.
- Record, use, display and disclose in a video and/or other media intended for public consumption statements and/or information provided by me concerning myself and/or my family.
- Use the activities listed above for direct mail, advertising, public relations, website, email, social media (e.g., Facebook, Twitter, etc.) and other online efforts related to the YWCA of Minneapolis.
- Use my name and the names of members of my family in conjunction with the activities listed above.

With respect to the above, I relinquish to the YWCA of Minneapolis all rights, title and interest I may have in all originals, edited versions, reproductions, and copies of any video and/or audio recording(s), prints, negatives, digital images and photographs in which my or members my family’s name, image, statements, information, and/or voice is used (the “Materials”).

I also irrevocably grant the YWCA of Minneapolis permission to copyright, if applicable, the Materials, and to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the Materials in any manner and for any reason the YWCA of Minneapolis may deem proper, including the right to use the same for purposes of advertising or trade.

By signing this Publicity Consent Release, I acknowledge that the YWCA of Minneapolis is not responsible for the
unauthorized use of the Materials by unrelated third parties. I hereby release the YWCA of Minneapolis from liability for any damages that may arise from the unauthorized use of the Materials by a third party.

NOTE: If you should no longer like the YWCA of Minneapolis to use your image in its awareness and education materials and activities, please contact the YWCA of Minneapolis. Due to the distribution and printing timelines, some of the materials the YWCA of Minneapolis may not be able to remove your image immediately from its pieces, but will do so as soon as those print pieces are scheduled for reprinting or new production. Print materials that are distributed to public audiences may not be recalled once distributed. Materials used for emails, website, social media or other online efforts may be removed from YWCA sites and networks, but due to the nature of the internet, may remain available online through other sources indefinitely.
Name of Minor Child
Parent/Guardian Signature
By typing my full name in the box below, I consent to the above for the child(ren) listed. This is equivalent to my signature.
Youth Attendance Agreement
All youth and expected to attend and participate in programming throughout its 10-week duration. Absences must be communicated to program staff. Youth are expected to attend group session on time and will not be permitted to attend programming if more than 15 minutes late. YWCA Minneapolis has zero tolerance for physical fighting and/or threatening behavior. Any youth who engage in an act of violence will be removed immediately.
Youth Signature*
By typing my full name in the box, I consent to the above listed. This is equivalent to my signature.
Parent/Guardian Signature*
By typing my full name in the box, I consent to the above listed. This is equivalent to my signature.
Today's Date*
MM slash DD slash YYYY
Comments
This field is for validation purposes and should be left unchanged.

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Girls RAP Participation Information Form

Girls RAP Participation Information Form

Register for Girls RAP

Girls RAP Participation Information Form

Step 1 of 2

Youth Information

Family Information

Parent/Guardian Consent

Publicity Consent

Youth Attendance Agreement