Student's Legal Name *
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.
NIMS (Starts 2/6 - Monday) TMS (Starts 1/30- Monday) TCMS (Starts 1/25 - Wednesday) ARS (2/25 - Wednesday) LMS (Starts 2/1 - Wednesday) WIMS (Starts 2/9 - Thursday) EIMS (Starts 2/2 - Thursday) OMS (Starts 1/26 - Thursday) BGCP (Starts 1/30 - Monday) Student's Address
* Student's Phone# *
Enter parent's number if you do not have a phone.
Student's Email *
Student's Age * Student's Birth Date * Student's Grade * 6th Grade 7th Grade 8th Grade Student's Contact Types
Select the acceptable ways to contact/inform your student
How did your child/student hear about TruthGirlz?
Please check all that apply
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)
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
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
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)
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)
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? * 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)
Emergency Contact Relationship to Student * Emergency Contact Phone# *