TriCity Family Services

STEP ONE
ENTER INFO
STEP TWO
CONFIRMATION
STEP THREE
RECEIPT

Register your daughter/s below to participate in True North Vision Board Workshop for Girls (created by Navigate Adolescence) on Saturday, February 6, 2021 (9:00 AM-12:30 PM) via Zoom, brought to you by TriCity Family Services, Navigate Adolescence, and the Geneva Coalition for Youth with the support of Geneva CUSD 304.

Please note that ONLY a parent/guardian of a True North Vision Board Workshop for Girls participant may complete this registration due to the permission/waiver that is included.

Registration Fee for True North Vision Board Workshop for Girls participants:
$15* per 6^th, 7^th, or 8^th- Grade Girl

Please complete your registration below. Once your transaction is complete,
you will receive a receipt via email from Acceptiva.

*Fee reductions and scholarships are available for those who qualify. If you want to request a fee reduction or scholarship, please email compass@tricityfamilyservices.org or call Michelle Clark, Director of Emotional Wellness Programs, at TriCity Family Services at 630.232.1070, ext. 336, to receive a code that must be used in this on-line registration.

Qty

Description

Amount

Total

True North Vision Board Workshop for Girls Registration(s)

$15.00

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per 6^th, 7^th, or 8^th Grade Girl

CODE to Register with an Alternative Fee or Scholarship:

---

CODE to Register with a Voucher emailed to you from Navigate Adolescence:

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Total: $0.00

True North Vision Board Workshop for Girls Information

Daughter’s First Name: *

Daughter’s Last Name: *

School – Please choose from a list below or type in the “Other School” box for a school name that is not listed.

Geneva CUSD 304 Schools:

St. Charles CUSD 303 Schools:

Batavia Public School District 101 Schools:

Kaneland CUSD 302 Schools:

Central CUSD 301 Schools:

Downers Grove Districts 58 & 66, & D68 & D60 & D61 Schools:

Private Schools:

Other School:

Please type the full name of the school - Homeschooling is listed above as an option in each district.

Grade Level: *

Will your daughter be attending a Navigate Adolescence workshop for the 1st or 2nd (or more) time?

Attending for the: *

List Friends for Your Small Group to Virtually Participate Together OR Make New Friends: *

Friends will be placed together if all friends register and list each other during registration.
Additional participants may be added to complete the group.

What do you want the facilitators of True North Vision Board Workshop for Girls to know about your child to help make the best possible workshop experience for your daughter?

Helpful Info about Your Child:

Additional Information

Participant Address: *

City, State and Zip: *

When TCFS seeks grants to help offset the costs of providing Emotional Wellness Programs such as True North Vision Board Workshop for Girls, TCFS is often asked to report on the numbers of participants per township.

Township *

To help us with a current grant application and with future program planning, do you have one or more children age 5 years-old or younger?

Children age 0-5:

Telephone of Parent/Guardian to contact, if necessary, about the registration, but please note that email will be the primary method of communicating event updates.

Telephone: *

Please add Compass (email address: compass@tricityfamilyservices.org) to your email contact list to try to avoid email being misdirected to your Junk mailbox.

E-mail: *

Parent/Guardian e-mail to share event updates.

Emergency Contact: *

Relationship to Participant/s: *

Phone: *

Phone number where you can be reached during the event/Emergency Contact.

Alternate Emergency Contact:

Relationship to Participant/s:

Phone:

Alternate Phone number where you can be reached during the event/Emergency Contact

PERMISSION FORM FOR TRUE NORTH VISION BOARD WORKSHOP FOR GIRLS AND LIABILITY WAIVER

I give my permission for my child/children to attend the True North Vision Board Workshop for Girls event on 2/6/2021 via Zoom. I hereby release and indemnify Navigate Adolescence, Inc., and its officers, TriCity Family Services (TCFS) and its officers, agents, employees, and volunteers, the Geneva Coalition for Youth and its officers and volunteers, Geneva Middle School South, Geneva CUSD 304, St. Charles CUSD 303, Batavia Public School District 101, Kaneland CUSD 302, and Central CUSD 301, the event sponsors and volunteers from any liability arising from any claims, damages, or injuries of any kind or nature whatsoever from my child/children's participation in this event. I understand that I will be promptly notified in the event of any serious concern that arises about my child's/children's participation in the event. I also recognize that she will be withdrawn from the event if TriCity Family Services facilitators feel that she poses a risk to the safety or well-being of or a significant distraction to the participants in the True North Vision Board Workshop for Girls event. I give consent for my child's/children's anonymous survey responses about the workshop to be used in communications with funders, publications, advertisements, brochures, websites, etc. by Navigate Adolescence and TriCity Family Services. I have read and fully understand the terms of this release.

The information presented at True North Vision Board Workshop for Girls is provided as a service to the community. The information shared is not intended to serve as, or substitute for professional counseling. All information shared will be kept in strict confidence by all TCFS and Navigate Adolescence personnel unless matters which indicate possible harm to or by a participant are revealed. All True North Vision Board Workshop for Girls event staff and volunteers are mandated reporters. Confidentiality among the girls participating in True North Vision Board Workshop for Girls will be encouraged but cannot be guaranteed.

Permission and Liabilty Waiver: *

I have read and agree to the terms of the above “Permission Form for True North Vision Board Workshop for Girls & Liability Waiver”.

If you chose not to agree, then you will not be able to use the online registration process for True North Vision Board Workshop for Girls. If you have questions, please call: Michelle Clark, LCPC, NCC, Director of Emotional Wellness Programs at TriCity Family Services (630)232-1070, ext. 336, or visit www.tricityfamilyservices.org for more information about True North Vision Board Workshop for Girls.

Payer Information

First Name: *

Last Name: *

Billing Address: *

This is the address where your credit card statements are mailed.

Address 2:

City: *

State / Province: *

Zip Code: *

Country: *

Telephone: *

E-mail: *

A receipt will be e-mailed to this address.

Questions? Call: Michelle Clark, Director of Emotional Wellness Programs at TriCity Family Services (630)232-1070, ext. 336. Or, email compass@tricityfamilyservices.org. You can also visit www.tricityfamilyservices.org for more information about True North Vision Board Workshop for Girls.

Your Payment Information

Name on Card:

Card Number:

Security Code:

Expiration Date: