TG Middle School Registration Form

Student's Name*

First Last

Middle School Attending*

Parent or Guardian should select the middle school that their student attends. And note that the Middle School program begins at 3:15 or 3:30pm and ends at 5pm.

Student's Address*

Street Address Address Line 2 City State ZIP Code

Student's Phone#*

Enter parent's number if you do not have a phone.

Student's Email*

Student's Age*

Student's Birth Date*

MM

DD

YYYY

Student's Grade*

Student's Contact Types

Select the acceptable ways to contact/inform your student

Mail
Email
Phone
Text

How did your child/student hear about TruthGirlz?

Please check all that apply

My friend invited me
My school announced it
My church announced it
My counselor recommended it
I've been in TruthGirlz before

Please note name friend that recommended TruthGirlz and/or school that you were involved in TruthGirlz in the past.

Primary Contact Permission & Information

Parent or Guardian Name*

(Parent, Guardian, Care Giver, Custodial Party)

First Last

Parent or Guardian's Relationship to Student*

Parent or Guardian's Phone#*

Parent or Guardian's Email*

Parent or Guardian's Contact Types

Select the acceptable ways to contact/inform Parent or Guardian

Mail
Email
Phone
Text

TruthGirlz Conduct Expectations

1 - I will conduct myself according to the standards and expectations outlined in Iredell Statesville Schools Student Handbook particularly the: Network/Internet Acceptable Use Agreement Student Behavior Policies Student Code of conduct (Scripture Reference: 1 Peter 2:13-14; Titus 2:7-8; Romans 13:1) ____________________________________________________________________ 2 - I will neither use my cell phone, laptop or other distractions nor create other distractions during TruthGirlz meetings. (Scripture Reference: 1 Cor 7:35, Col 3:2) ____________________________________________________________________ 3 - I will give others the same respect I would like them to give me. (Scripture Reference: Mark 12:31, 1 Peter 2:17, Matt 7:12) ____________________________________________________________________ 4 - I will be a healthy example to others in how I speak, behave and present myself. (Scripture Reference: Timothy 4:12, Eph 4:29) ____________________________________________________________________ 5 - I will show love to the world around me with actions and truth. (Scripture Reference: 1 John 3:18, Romans 13:10) ____________________________________________________________________

TruthGirlz Response Plan

1 - Review TruthGirlz expectations with Mentor and give verbal apology (if relevant) (Scripture Reference: James 5:16) ____________________________________________________________________ 2 - Review TruthGirlz expectations with Mentor; Solution Session with Family*; written apology as relevant; email to notify parent. (Scripture Reference: Proverbs 14:9 Matthew 18:15-16) ____________________________________________________________________ 3 - Review TruthGirlz expectations and Solution Plan with Mentor; Support Meeting with Family*, Mentor and Site Coordinator; Verbal and Written apology as relevant; parent notification; Restart Points. (Scripture Reference: 1 Thessalonians 5:11, Hebrews 12:14) ____________________________________________________________________ 4 - Review TruthGirlz Expectations /Reevaluation of Solution Plan; Support Meeting with Family*, Site Coordinator, Parent; Loss of Boutique Privilege. (Scripture Reference: Luke 17:3) ____________________________________________________________________ * FAMILY is a TruthGirlz term for our student accountability teams ________________________________________________________

Confidentiality Policy of The Pregnancy Resource Center of Statesville

The Pregnancy Resource Center of Statesville will hold in strict confidence all the information provided to them except as required by North Carolina State Law or when necessary to protect other or clients against a threat of harm: in the professional's judgement, they feel the client is likely to do serious harm to themselves or others; abuse or neglect of children, elderly or any defendants; they are ordered by the court to provide information; the client gives specific written permission. ****** Disclosure Statement ****** When disclosure is required, only information that is essential will be revealed. The client will be informed of such disclosure to other agencies.

Parent or Guardian's Permission Statements*

Please check all Permission Statements that you agree with (all are required for your student/child to participate in the TruthGirlz program)

Select All
Yes, my child has my permission to attend TruthGirlz after school until 5pm. I understand that transportation is not provided and I will ensure that she is picked up at 5pm. If she is left after TruthGirlz has ended more than 20 min and an authorized pick up person cannot be reached, school policy dictates that the sheriff's department must be contacted.
Yes, I give the PRC of Statesville permission to take and to use photos of my child for promotional purposes of TruthGirlz and the PRC.
Yes, I have reviewed the TruthGirlz Expectations and Response Plans with my child. I understand and agree with them and I will support my daughter's commitment to them by encouraging her and holding her accountable.
Yes, My child and I understand that TruthGirlz participants will be covered by the confidentiality policy of the Pregnancy Resource Center of Statesville.

Parent or Guardian's Signature*

I acknowledge that I have read, understand and agree with all the above statements.

Student's Permission Statements*

Please check all Permission Statements that you agree with (all are required for you to participate in the TruthGirlz program)

Select All
Yes, I have read the TruthGirlz Expectations and Response Plan along with my parent or guardian and I agree to hold myself accountable to them.
Yes, I have read and understand the confidential policy of the Pregnancy Resource Center of Statesville.

Student's Signature*

I have read, understand and agree with the TruthGirlz Expectations, Response Plan and Confidentiality Policy. My signature is my commitment to the TruthGirlz Expectations.

Reading, writing, memorization and physical activity are all routine parts of the TruthGirlz experience. Are there any modifications or medial concerns that you would like us to be aware of to maximize your child's experience with us?*

Yes
No

If yes, please describe any information that would be helpful for us to know to best serve your child/student.

Alternate Contact Information

Emergency Contact Name*

(the next person to call if the Primary Contact cannot be reached)

First Last

Emergency Contact Relationship to Student*

Emergency Contact Phone#*

Grow WELL - Love WELL - Live WELL

TG Middle School Registration Form

TruthGirlz Middle School Registration Form

Primary Contact Permission & Information

TruthGirlz Conduct Expectations

TruthGirlz Response Plan

Confidentiality Policy of The Pregnancy Resource Center of Statesville

Alternate Contact Information