2019 Girls' Summit Youth

Fall Session 2019 Girls' Summit Youth

Please complete one application per youth participant. Tuition: $320 per week per child (includes $20 program fee to cover field trips and lunch in Chinatown). Once application is received, we will contact you for online payment. If you have any questions, please contact Brittany Montilliano at (808) 695-2635.
Application
Parent's Name*

First NameLast Name
Parent's Email*
example@example.com
Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Daytime Phone Number*

Area CodePhone Number
Fall Session- October 7- October 11, 2019*

October 7-11, 2019
Drop-off time (drop off is from 8am - 8:30am)*

:HourMinutesAM/PM Option
Youth Participant Information
Youth's Name*

First NameLast Name
Youth's Date of Birth*

MonthDayYear
Date
Youth's Age*
Scholarships are available to applicants who meet one or more of the following criteria. Please select all that apply to be considered.

MinorityDisadvantagedLow income
If you are applying for a scholarship, please write a 100 word essay OR submit a 1 minute video on why your child should be considered for a scholarship.
Scholarship Video Submission

Upload video here

Cancelof
I authorize the following person to pick up my child(ren) in my absence. IMPORTANT: Leaving this section BLANK means I do NOT authorize anyone other than the person named above to pick up my child.
Authorized Individual Name (1)

First NameLast Name
Relationship
Daytime Phone Number

Area CodePhone Number
Email
example@example.com
Authorized Individual Name (2)

First NameLast Name
Relationship
Daytime Phone Number

Area CodePhone Number
Email
example@example.com
Emergency Contact
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Relationship*
Email*
example@example.com
Phone Number*

Area CodePhone Number
Medical History

All participants are required to keep contact information current.

Significant medical history/conditions we should be aware of (heart condition, epilepsy, ect.)
**Note: If there is any condition to the contrary, describe in the medical information space provided below. MEDICAL INFORMATION: This is very important! It is included to assist designated personnel in assuring your child’s wellbeing. Please list seizures, diabetes, muscular or skeletal problems, or any other medical condition you would like called to our attention. Feel free to call Program Manager, Colleen McAluney, at: (808) 695-2636 in advance of the activity date to discuss any specific health problems, but please indicate below as well.
Allergies (medicine, insect bites, food, etc.)Please list allergies/name
Please list any food restrictions
In case of emergency, my choice of hospital is *
Parent/Guardian Consent Form for Field Trips
Field Trips vary weekly and will include walking to Hawaii State Library, Foster Botanical Garden, Queen’s Medical Center and Honolulu Museum of Art and many more. We will notify parents the week before of confirmed upcoming field trips.
It is understood that with any activity there is a chance for accidents, therefore, I/we consent to medical treatment and assume full responsibility and liability for any and all expenses, damage, accident, illness, injury or medical expense of and to my child or our property resulting from such participation. I attest and affirm that the participant has no limitation that should prevent participation in the activity and I have not been advised or informed by anyone to the contrary. (SEE NOTE BELOW) I further agree to inform the program coordinator should my child’s physical condition change in any way and any time so as to affect his/her participation in the activity herein named above.
Parent/Guardian Signature

Clear
Date*

MonthDayYear
Date
Participant Medical and Liability Waiver/Photo Release
In consideration of YWCA O'ahu accepting my (or the participants) application for voluntary participation in YWCA programs, activities, and/or related events at the YWCA facility, I, the undersigned participant (or legal guardian of a minor participant), hereby waive all claims and or causes of action, including negligence, against the YWCA O'ahu and its officers, directors, employees, agents and representatives arising out of my participation in the YWCA programs, activities, and/or related events at the YWCA facility. I, intending to be legally bound for myself, my successors, heirs, legal representatives, executors, administrators and assigns, do hereby release, hold harmless, and discharge the YWCA O'ahu officers, directors, employees, agents and representatives, from any and all liability, including negligence, in connection with my participation in YWCA programs, activities, and/or related events at the YWCA facility.

I understand and acknowledge that participation in YWCA programs, activities, and/or related events at the YWCA facility could result in loss of, or damage to, my or another person’s property, serious injury to my or another person’s body, including mental or emotional injury or trauma, and/or death. Knowing, understanding and fully appreciating all of these consequences, I hereby voluntarily and willingly assume all risks and damages associated with my child's participation.

I have read this waiver and understand the terms in it, and its legal significance. This waiver and release is freely and voluntarily given with the understanding that the right to legal resources against the YWCA O'ahu is knowingly given up in return for allowing my participation in the YWCA programs, activities, and/or related events at the YWCA facility. My signature on this document is intended not only to blind myself, but my successors, heirs, legal represent, executors, administrators, and assigns, as well.

I consent for my child to receive medical treatment, which may be advisable in the event of illness, or injuries suffered by me during YWCA programs, activities, and/or related events at the YWCA facility.

If participant is under 18 years old: Should parent(s) or authorized person(s) not be available, I authorize the YWCA of Oahu to arrange for emergency transport and medical attention to the nearest hospital.

I grant permission to the YWCA O'ahu to use photographs, slides, or videotapes in which I or my child may appear, for YWCA education, promotion or publicity purposes and waive all claims for compensation for such use.

I HAVE READ THIS WAIVER AND AGREE TO ITS TERMS.
Participant's Name*

First NameLast Name
Parent's Name*

First NameLast Name
Date*

MonthDayYear
Date
Parent/Guardian Signature

Clear
Girls' Summit Youth 2020 Program Survey
Please select your location preference(s) for the Girls' Summit Youth Program 2020.

YWCA Oahu, Laniakea (Downtown Honolulu)YWCA Oahu, Kokokahi (Kaneohe)
Should be Empty:

Fall Session 2019 Girls' Summit Youth

Application

Parent/Guardian Consent Form for Field Trips

Participant Medical and Liability Waiver/Photo Release

Girls' Summit Youth 2020 Program Survey