2015 Worthy Girls, Worthy Lives Program Application

2015 Worthy Girls, Worthy Lives Program Application

2015 PROGRAM APPLICATION

PLEASE MAIL OR E-MAIL THIS APPLICATION TO:

WORTHY GIRLS, WORTHY LIVES, INC.

PO BOX 21195

CATONSVILLE, MD 21228

(443) 621-9326

APPLICATION DEADLINE: May 25, 2015

DESCRIPTION

Worthy Girls, Worthy Lives, Inc. is a 501© 3 nonprofit girls’ empowerment and mentoring organization. Worthy Girls, Worthy Lives inspires girls ages 9-12 to strengthen their self-worth by participating in relevant, engaging activities that will promote a stronger positive identity, social skills, and service learning opportunities. WGWL also provides tools and a platform to empower the girls to make wise decisions throughout important transitions in their lives. For admission into the program, all candidates must complete the application process. Please read the eligibility requirements, terms and conditions below before completing the application. Please contact us if you have any additional questions.

PROGRAM DATES: Saturdays from 11am-2pm (June 6th, June 13th, July 11th), Wednesdays, June 17th and June 24th from 5:30pm-7:30pm) Closing is on July 22nd

COST OF THE PROGRAM: FREE

SATURDAY SESSION LOCATION: Enoch Pratt Library-Edmondson Ave. Branch; 4330 Edmondson Ave. Baltimore, MD 21229

ELIGIBILITY REQUIREMENTS: We are looking for applicants who…

v  Live in the Baltimore Metropolitan Area

v  Are girls between the ages 9-12

v  Have a desire to improve in a specified personal, social, or spiritual area of her life

v  Exhibit leadership potential

PROGRAM TERMS & CONDITIONS

v  Full participation in each Saturday session is required

v  All participants must follow the Worthy Girls, Worthy Lives discipline policy and guidelines as established by the facilitators and staff.

PROGRAM SCHEDULE

v  The WGWL program will take place on 3 Saturdays from 11:00AM-2:00PM, and 2 Wednesdays from 5:30-7:30PM. Occasionally, Special Events and/or Field Trips will be off-site and times will vary.

v  Times for program are subject to change at any time; participants will be notified if and when program times are amended.

PART I: APPLICANT/CHILD INFORMATION

(Please Print Clearly in Black or Blue Ink)

APPLICANT’S NAME: ______
FIRST MI LAST

DATE OF BIRTH: ___ -___-____ AGE AND GRADE AT APPLICATION DATE:______

HOME ADDRESS:______

______

HOME NUMBER: (___)______CELL PHONE:(___)______

E-MAIL: ______FOOD ALLERGIES______

CHILD’S T-SHIRT SIZE: SMALL MEDIUM LARGE X-LARGE

PART II: PARENT/GUARDIAN INFORMATION

PARENT/GUARDIAN NAME: ______

RELATIONSHIP TO APPLICANT:______

MAILING ADDRESS:______

HOME NUMBER: (____)______CELL PHONE (____)______

WORK NUMBER: (____)______E-MAIL:______

DOES YOUR CHILD HAVE PERMISSION TO TRAVEL ALONE?______

PLEASE NAME THE PERSON AND OR PERSONS WHO WILL BE PICKING YOUR CHILD UP TO AND FROM THE PROGRAM______
PART III: EMERGENCY CONTACT INFORMATION

EMERGENCY CONTACT NAME: ______

RELATIONSHIP TO APPLICANT: ______

HOME NUMBER: (___)______CELL PHONE (___)______

WORK NUMBER (___)______E-MAIL:______

PART IV: ACADEMIC INFORMATION

CHILD’S SCHOOL /ADDRESS______

SCHOOL TELEPHONE NUMBER (____)______

PART V: CHILD’S EXTRACURRICULAR ACTIVITIES

ACTIVITY / DESCRIPTION

PART VI: CHILD’S LEADERSHIP EXPERIENCE

ACTIVITY / POSITION / RESPONSIBILITIES

PART VII: SHORT ANSWER QUESTIONS

FOR APPLICANT: Please respond to each of the following questions.

1.  Why do you want to attend the Worthy Girls, Worthy Lives program?

______

______

2.  Name one special quality that you like about yourself and why? ______
______n program times are amended.f-site

______

PART VII: SHORT ANSWER QUESTIONS

FOR THE PARENT/GUARDIAN: Please respond to each of the following questions.

1.  Name one specific reason why you believe your child, family member, or friend can benefit from being involved in the Worthy Girls, Worthy Lives Program?

______

______

2.  What is one positive quality that you believe that your child, family member, or friend can contribute to the program as a whole?

VIII. MEDIA RELEASE & DISMISSAL DISCLAIMER

APPLICANT’S NAME: ______

PHOTOGRAPHY/VIDEO RIGHTS AND PERMISSION

During the course of the Worthy Girls, Worthy Lives program and all associated involvement, I understand that my child’s photo and or video may be taken. I hereby give my consent to use any such photo or video in conjunction with promotional use, the WGWL website, social media publicity and/or media coverage.

PARENT/GUARDIAN SIGNATURE: ______

DATE: ______

DISMISSAL DISCLAIMER

I understand that Worthy Girls, Worthy Lives, Inc. reserves the right to change, cancel, or modify the program’s schedule, activities, themes, or staff at any time. Worthy Girls, Worthy Lives, Inc. also reserves the right to withdraw any participant whose conduct is deemed disruptive and/or harmful to peers, staff, or volunteers.

Any violation of Worthy Girls, Worthy Lives, Inc. rules and/or policies will result in automatic and immediate dismissal from the program. Worthy Girls, Worthy Lives, Inc. cannot be held liable for personal injury, damage, or loss of personal property.

APPLICANT’S SIGNATURE:______DATE:______

PARENT’S SIGNATURE: ______DATE:______

ALL APPLICATION MATERIALS SUBMITTED TO WORTHY GIRLS, WORTHY LIVES, INC. BY OR FOR THE APPLICANT ARE CONFIDENTIAL.

ALL APPLICATIONS MUST BE FULLY COMPLETED FOR PROGRAM ADMISSION.

INCOMPLETE APPLICATIONS WILL NOT BE CONSIDERED.