GHRO 25-26 Application (Private)

GHRO Your Future 2025-2026

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.

The GHRO Your Future program is offered at no cost to students and their families. Spaces are extremely limited and are prioritized for students who are committed to attending every program session and becoming leaders in the program and their community. Students who cannot commit to the program schedule are encouraged instead to attend Afterschool Wednesdays at the Femergy® Center, launching in the fall.

By filling out this application, you are registering your interest in your student attending. A Femergy® staff member will contact you with an update on your application status in early September.

If your application is approved, you MUST attend a mandatory orientation prior to the program kick off on September 13th. Additional information will be provided to you at the time of approval.

Guardian First Name

Guardian Last Name

Guardian's Email Address

Guardian's Phone Number

Student's First and Last Name

Guardian's relationship to student (mother, father, grandmother, aunt, etc):

Student's Address Information:

Multi-line address

Country/Region

Address

City

Zip / Postal code

Guardian's Address (if different):

Student's Date of Birth

Month

Day

Year

Student's School

Student's Grade (25-26 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.

Household Size:

Please input the number of people living in the student's household.

Household Income

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

Yes

Pre-Program Information

How did you learn about the GHRO Your Future program?

Has your student participated in the GHRO Your Future program before?

Yes

Please have your student explain in the space below what they would like to achieve by attending the GHRO Your Future program. It is important that we understand each student's interest, so please have your student answer directly.

Has your student had a mentor before?

Yes

Does your student have an interest in having a mentor?

Yes - Individual Mentoring

Yes - Group Mentoring

No interest in mentorship

Unsure

What style of mentorship is your student interested in?

In Person

Virtual

Not interested in mentorship

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?

What career fields is your student interested in?

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

No other commitments currently or anticipated

Other

Do you anticipate needing transportation support for your student?

Frequently

Occasionally

Never

Is your student interested in attending Afterschool Wednesdays (tutoring and study support sessions) at the Femergy Center?

Yes

Unsure at this time

GHRO Your Future programming is held bi-monthly on Saturdays from late September through early May. Our tentative program schedule is as follows:

September 27th
October 11th
October 25th
November 1st
November 15th
December 6th
December 13th
January 10th
January 24th
February 7th
February 21st
March 7th
March 21st
April 4th
April 11th
April 25th

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 committed to this program.

We want to provide the best support possible for your student and family. Would you, as the parent or guardian, be interested in attending parent gatherings to connect with other program parents and receive additional support and resources?

Yes

If yes, is there anything specific you'd like to see at these meetings?

Emergency Contact Information

Emergency Contact First and 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.

Insurance Company:

Policy Holder:

Group Number:

Policy 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 details:

Does your student have an IEP or 504 plan? Are there any accommodations we can provide to ensure your student has the best experience possible?

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):

Release & Declarations

Parental Release

I agree that my above named student may attend the 2025-2026 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 the program that needs immediate treatment, I agree to my child receiving first aid and medical treatment, including lifesaving treatments, as may be considered necessary by a licensed medical provider.

I 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 program 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.

Please read the following Parental Consent & Liability Waiver for Transportation Services carefully:

Femergy® is pleased to offer transportation services for students through a rideshare, as deemed necessary and feasible. This service is fully paid for by our organization and aims to ensure safe, reliable, and convenient travel for our participants.

Please carefully review and sign this consent and waiver form to authorize your child to use the rideshare transportation services under the supervision and guidance of Femergy® if you anticipate needing transportation support.

1. Consent for Rideshare Transportation

I hereby grant permission for my child to use rideshare transportation services. I understand that Femergy® will arrange and pay for the rideshare rides and that the service will be used exclusively for transportation to and from GHRO Your Future programming activities.

2. Acknowledgment of Risks

I acknowledge and understand that while Femergy® has taken measures to ensure the safety and reliability of transportation, there are inherent risks involved in using any rideshare service, including but not limited to traffic accidents, delays, or other unforeseen incidents.

3. Release of Liability

By signing this waiver, I agree to release, discharge, and hold harmless Femergy®, its staff, volunteers, and affiliates from any and all liability, claims, or demands for personal injury, property damage, or any other loss or damage resulting from or in connection with my child’s use of rideshare services, except in cases of gross negligence or willful misconduct by Femergy®.

4. Medical Emergencies

In the event of a medical emergency during transportation, I authorize Femergy® and/or the rideshare driver to take appropriate actions to ensure the safety and well-being of my child, including contacting emergency medical services.

5. Contact Information

I agree to provide accurate and up-to-date contact information to Femergy® and ensure that I or an emergency contact can be reached at all times during the scheduled transportation.

I acknowledge that I have read, understood, and agree to the terms of the Parental Consent & Liability Waiver for Transportation Services.

Confirmation of Application

I understand that by filling out this application, I have completed the first step to enroll for my child for the 2025-2026 GHRO Your Future program cycle.

I understand that a Femergy® staff member will contact me regarding the approval of my student's application. I understand that there are limited spaces available for the GHRO Your Future program, and that this application does not guarantee acceptance.

If my student is accepted, I understand that I must attend a mandatory program orientation on Saturday, September 13th from 9:15 - 10:15 AM. Full details will be emailed.

I hereby 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.

Signature

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Print Name

Date Signed

After you press submit, you will be redirected to the GHRO Your Future page. You will receive a confirmation email within 10 minutes of submission. If you have questions, please contact Director of Youth Programs & Engagement Randi Ellis at randi@femergy.org