GHRO 24-25 Application (Private)

GHRO Your Future
2024-2025
Cycle Application

We recommend filling out this application on a desktop computer. Please expect to spend 15-20 minutes completing this application thoroughly. If you need assistance filling out this application, please contact us at info@femergy.org.

By filling out this application, you are registering your interest in your child attending. To confirm your child's registration, you MUST attend a mandatory orientation prior to the program kick off on September 28th. The date and time of the orientation will be communicated to you via email and text in the coming weeks using the contact information provided in this application.

Guardian First Name

Guardian Email Address

Student's First and Last Name

Guardian Last Name

Guardian Phone Number

Relationship to Student (mother, father, grandmother, aunt, etc):

Student's Address

Guardian's Address (if different than student's)

Student's Date of Birth

Student's School:

Student's Grade (24-25 School Year):

Demographics

Demographic information helps us best quantify where the need is in our community, who we're serving, and what additional resources we can provide to families. This information is confidential.

Student's Race and Ethnicity (select all that apply):

Household Size:

Does your student qualify for free or reduced lunch at school?

Yes

Pre-Program Information

How did you find out about the GHRO Your Future program?

Has your student ever had a mentor before?

Yes

Does your student have an interest in having a mentor?

Yes, an individual mentor

Yes, group mentoring

Unsure

What style of mentorship is your student interested in?

In-Person

Virtual

Not interested in mentoring

What is your student looking for in a mentor? Consider specific qualities that may be important to you, including hobbies, careers, values, etc.

We would love to get to know your student. What are her interest, hobbies, and how would you describe her?

How would she describe herself? Please have your student answer this questions herself.

What does your student hope to gain from the GHRO Your Future program?

What career fields is your student interested in?

Which areas are you most interested in recieving support in?

Creating education goals/plan

Creating personal goals/plans

Exploring future career opportunities

Expanding knowledge of involvement in the community

Balancing the demands of life , school and extra curricular

Coping with transition

Having guidance in decision making

Having an accountability partner

Developing leadership skills

Other

Does your student have additional commitments?

Yes, my student has a job

Yes, my student participates in extracurriculars at school

Yes, my student is involved with another community organization

My student anticipates getting a job within the next year

My student anticipates joining an extracurricular in the next year

My student anticipates joining another community organization in the next year

Other

No other committments currently or anticipated

GHRO Your Future programming is held every other Saturday from late September through early May. To accommodate holidays, select program dates will be on back to back Saturdays. Our tentative program schedule is as follows:

September 28th
October 12th
October 26th
November 9th
November 23rd
December 7th
December 14th, 2024
January 11th, 2025
January 25th, 2025
February 8th, 2025
February 22nd, 2025
March 8th, 2025
March 22nd, 2025
April 5th, 2025
April 19th, 2025
May 3rd, 2025
May 8th, 2025 (Thursday evening capstone ceremony)

Monthly mentor check-ins will fall outside of these times, at the discretion of the mentor and mentee.

The GHRO Your Future program requires commitment and perseverance from both students and parents. Attending workshops is crucial to student success in the program. Can you commit to consistent and punctual attendance?

My student and I are committing to this program.

Emergency Contact Information

Emergency Contact First & Last Name:

Emergency Contact's Phone Number:

Emergency Contact Relationship to the Student:

Medical Information and Consent

Providing this information helps ensure every participant is safe and healthy while away from home. This information is confidential.

Policy Holder

Insurance Company:

Policy Number:

Group Number:

Does your student suffer from any medical, physical, emotional or behavioral conditions which might affect hers or others safety while in the program? (i.e. vertigo, asthma, heart condition, diabetes, epilepsy, etc.):

Yes

If yes, please provide additional details:

Does your student have any food, medication, or environmental allergies?

I give permission for staff to give my student the following (select all that apply):

Acetaminophen – Tylenol or Generic

Ibuprofen – Advil or Generic

Cough Suppressant – Robitussin or Generic

Hydrocortisone Ointment

Antacid – TUMS, Mylanta, Maalox, or Generic

Aspirin

Antihistamine – Benadryl or Generic

Decongestant – Sudafed or Generic

Antibiotic Ointment

Release and Declarations

Parental Release

I agree that my above named student may attend the 2024-2025 GHRO Your Future program hosted by Femergy® at the Femergy® Center (49 S Grant Ave, Columbus OH 43215) and other locations communicated throughout the program.

I give permission for my participant to take part in all of the activities described below. I acknowledge the need for responsible behavior and ability for my child to make sound decisions during the program, and follow all directions/rules.

I understand that I am responsible for my child’s actions and will be held financially responsible for any damage by my child and will pay for any and all repairs incurred by such damage.

I accept the Parental Release

Please read the following declarations carefully and check yes to agree:

In the event of an accident or an illness during this event that needs immediate treatment, I agree to my child receiving first aid and medical treatment from a including lifesaving treatments, as may be considered necessary by a licensed medical provider

I also authorize the transportation of my child, by ambulance if necessary, to the nearest available medical facility.

I understand the extent and limitation of the insurance coverage as provided by the organization sponsoring the event and that my medical insurance is primary, unless otherwise specified.

I will inform staff as soon as possible if there is any change in medical circumstances regarding my child between the date signed below and the start of this event.

Please read the following Release of Claims and Photo Release carefully:

I hereby agree to indemnify, defend, and hold harmless Femergy®, its Board of Trustees, and its officers, directors, employees, volunteers, agents, affiliates, and all others who could be held liable (collectively, “Femergy®”) from and against any and all claims, causes of action, lawsuits, losses, costs, damages, expenses (including, but not limited to, attorneys' fees) and liabilities due to any injury to or death of any person, or damage to or loss of any property, arising out of or related to Participant’s participation in such activities. I also hereby specifically agree to waive and release any and all claims against Femergy® arising out of or related to any such activities.

I hereby waive, release, discharge, and agree to hold harmless Femergy® from and against any and all liability, loss, damage, and claims of any nature which in any manner arise from or relate to such services or treatment. I understand that the participant’s participation in the above-referenced program and activities is performed under this specific understanding. I have read and understand the foregoing and voluntarily sign this Release of Claims with full knowledge of its contents and significance.

I hereby grant Femergy®, its program personnel and affiliates, permission to use the Participant’s likeness in publications related to the program and mission of the agency, without payment or further consideration. I understand and agree that these materials will become the property of Femergy®. I hereby authorize Femergy®, its program personnel and affiliates, permission to edit, alter, copy, exhibit, print, publish, electronically or otherwise, the photo(s) and or video(s) for their programs, events, bulletins, newsletters, websites, or any other lawful purpose. I have read and understand the foregoing and voluntarily sign this Photo Release.

I accept the Release of Claims

I accept the Photo Release

I understand that by filling out this application, I have completed the first step to enroll for my child for the 2024-2025 GHRO Your Future program cycle. To complete enrollment, I must attend a mandatory program orientation on Saturday, September 21st from 9:30 - 10:30 AM. Full details will be emailed.

I herewith affirm that my electronic signature was signed by myself with full knowledge and consent and am legally bound to the agreements made in this form.

Your Signature

Print Name:

Today's Date:

Thanks for submitting!

We have reached capacity for participation. To be notified if additional spots open up, please register for our waitlist below.

GHRO Your Future 2024-2025 Cycle Application