Girl Power Application Question Title * 1. Applicant Information Name Grade Birthdate Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code Email Address Phone Number Question Title * 2. Parent/Guardian 1 Information Name * Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code Email Address * Phone Number * Question Title * 3. Parent/Guardian 2 Information Name Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code Email Address Phone Number Question Title * 4. School Information School Name * Principal's Name Address City State -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP Code Email Address Phone Number Question Title * 5. I, the undersigned parent/legal guardian of the child named below, hereby consent to and give my permission for the following, the member: -Has my consent and permission to participate as a member of the Family Wellness Outreach Center of Georgia, Girl Power Inc.-Has my consent and permission to participate in all Girl Power Inc. activities, which may also include activities held at other locations.-Will be participating at her own risk and I, on his/her and my own behalf, hereby release, discharge and indemnify Family Wellness Outreach Center of Georgia, and its subsidiaries from all liability for injury to person or damage to property of myself and the Member arising out of participation in, and transportation associated with, Girl Power Inc.-Grants permission to Family Wellness Outreach Center of Georgia and the Girl Power Inc. to use the likeness, voice and words of the Member in television, radio, films, newspapers, magazines and other media, and in any form not heretofore described, for the purpose of advertising or communicating the purposes and activities of the Girl Power Inc. and appealing for funds to support such activities.*In the event of an accident or illness during Girl Power Inc. activities, I understand that reasonable effort will be made to contact the parent/guardian or emergency contact immediately. However, I am aware that if the injury or illness appears serious and the parent/guardian or emergency contact cannot be reached, the adult in charge will secure emergency medical care as needed.By signing below, you affirm that you have read and agree to the expectations and guidelines of the Family Wellness Outreach Center of Georgia Girl Power Inc. Child's name Guardian's Name Date Question Title * 6. Dear Potential Girl Power Inc. Member,As a Girl Power Inc., you will:• Learn to work effectively with youth from unique perspectives and backgrounds.• Engage youth and your peers effectively.• Attend all Girl Power Inc. Sessions.• Provide feedback on program success and goals upon completion of the program.• Serve as an overall ambassador of the Sexual Risk Avoidance Education reduction mission.• Represent Family Wellness Outreach Center of Georgia at various national, state and local conferences as well as press/media functions.*The Family Wellness Outreach Center of Georgia Girl Power Inc. is at-will and participants may be dismissed at the supervisor’s discretion due to failure to meet responsibilities.By signing below, you affirm that you have read the above expectations and guidelines, and agree to work, if selected, toward achieving these expectations and responsibilities for the duration of your participation in the Girl Power Inc. Name Date Question Title * 7. Code of ConductGirl Power Inc. understands that the organization requires the highest standards of behavior. The Girl Power Inc. member agrees to conduct herself in a manner that contributes to a sense of community among all students and forum staff and foster an atmosphere of mutual respect.The Girl Power Inc. member agrees to the following code of conduct:1. Behavior at all times should be such that it respectfully reflects Family Wellness.2. Girl Power Inc. members are expected to exhibit trustworthiness, respect, responsibility, fairness, and citizenship.3. As such, uses of tobacco, alcohol, or other illegal substances are not acceptable for Girl Power Inc. members. Participation in any of the above may result in automatic termination from Girl Power Inc.4. If a Girl Power Inc. member is found responsible for any criminal or legal offenses, such as stealing, vandalism, harassment, or assault, the member may face automatic termination from the organization.5. Accidents, injuries, or illnesses that affect attendance for Girl Power Inc.-related activities should be reported to the Girl Power Inc. Supervisor as quickly as possible.6. Inappropriate physical contact with other officers or members is unacceptable.Responsibilities and DutiesAs a Girl Power Inc. member, you are a representative of your home community as well as your organization. You have been selected because your ideas and your hard work embody our mission. As a result, it is also important to be aware that your actions also reflect on Family Wellness.The development and success of the organization’s programs and initiatives is affected by your performance in completing duties. As a result, it is extremely important to attend all meetings, to let us know in advance if you are unable to attend meetings and to be punctual. Your fellow Girl Power Inc. members will also rely on you to provide help and support.As a Girl Power Inc., you are a role model to other youth in the community, just like you. This is an opportunity and a challenge to practice important skills, and to guide and inspire. The example that you set, through your motivation, your energy, and your commitment, will affect not only your fellow Girl Power Inc. members, but also our engagement with youth around the country.Girl Power Responsibilities:• Regular attendance at meetings on time and participate • Complete 25 hours of community service • Pass ALL academic classes• Timely communication of successes, concerns, and questions• Managing your schedule• Working as a team, sharing responsibilities, and working through challengesI agree to the Family Wellness Outreach Center of Georgia: Code of Conduct and understand that if this conduct is not followed that I will be released from my position on the Girl Power Inc. Name Date Done
