GIRLS PROMOTING SAFETY (GPS) PERMISSION SLIP

Child's Name*

First Last

Parent/Guardian Name

First Last

Student's Email*

Student's School*

Student's Grade*

Students will be provided with a survey to complete at the beginning and the end of the GPS program. Please check the preferred written language for your child:

English
Spanish
Portuguese

Family’s Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parent/Guardian Phone Number

Parent/Guardian Email

Consent

I agree to the permission slip.

By checking this box, I give my child permission to participate in the GPS Program.

Photo Authorization and Release

Consent

I agree to the Photo Authorization and Release.

I hereby authorize the YWCA Central Massachusetts and Girls Inc. of Worcester, to publish any and all photographic portraits or pictures, or any part thereof, they have taken of me on this date in conjunction with the Girls Promoting Safety (GPS) Program or in which I may be included in whole or in part, whether apart from or in connection with, illustrative or written printed matter, story or news item, or for publicity, advertising or any lawful purpose whatsoever, in conjunction with my own name, or in reproductions thereof in color or otherwise.

I hereby waive all claims for any compensation for such use or for damages.

I hereby waive any right that I may have to inspect and/or approve the finished product or the advertising copy that may be used in connection therewith or the use to which it may be applied.

I hereby warrant that I am of full age and have every right to contract in my own name in the above regard. I state further that I have read the above authorization release, prior to its executive, and that I am fully familiar with the contents thereof.

Girls Promoting Safety Participant Demographic Questions

*All information provided on this form will be kept confidential.

Name of Participant

First Last

What is the participant’s birth date?

(Month/Day/Year)

What grade is participant in?

What is the participant’s ethnicity?

Hispanic or Latino
Not Hispanic or Latino

What is the participant’s race?

Asian American or Pacific Islander American
Black or African American
Hispanic, Latina, or Latin American
Middle Eastern / North African
Native American or American Indian
White, European American, or Anglo
Multiracial/multiple heritage

What is the participant’s primary language?

Which language do you speak most often at home?

What is the participant’s gender/sex?

Female
Male
Non-binary/Other

What is your family’s total household income each year?

Less than $10,000
$10,000-$20,000
$20,001-$30,000
$30,001-$50,000
More than $50,000

Which family members does the participant live with?

Two parents
Mother Only
Father Only
One parent at a time (joint custody)
Grandparent(s) or other relatives
Foster parent(s)
None of the above

How many people live in your household, including the participant?

Photo Authorization and Release

Girls Promoting Safety Participant Demographic Questions

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