TG Middle School Registration Form

Middle School Registration

Middle School Registration
Most middle school TruthGirlz groups meet immediately after school and end at 5pm. The SCS group ends at 4:30pm. Select your school in the form below for your meeting day and start date. REGISTERED PARTICIPANTS OF FALL 2023 ARE AUTOMATICALLY REGISTERED for Spring 2024. Please contact Jaden Crews or Regina Yount at our office (704) 871-0338 with any questions.
Student's Legal Name*
First Last
TruthGirlz Meeting Site*
For meeting site, select the middle school that the student attends UNLESS the girl will attend meetings at the Boys & Girls Club of the Piedmont. In this case, select BGCP as meeting site.
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*
Month
Day
Year
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)
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 each box stating that you and your child have read and agree to all requirements for participation in TruthGirlz.
- Select All
- 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.
- I give the PRC of Statesville permission to take and to use photos of my child for promotional purposes of TruthGirlz and the PRC.
- 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.
- 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*
Typing my name acknowledges 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. Typing my name in this box 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#*
Post Body

Crossroads Care Clinic | 1710 Davie Ave, Statesville, NC 28677704-871-0338contact@truthgirlz.org

Middle School Registration

Primary Contact Permission & Information

TruthGirlz Conduct Expectations

Confidentiality Policy of The Pregnancy Resource Center of Statesville

Disclosure Statement

Alternate Contact Information