PY25 Cross-City Mentee Registration Form

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SWSG Logo

Welcome to Strong Women, Strong Girls (SWSG)! We appreciate your decision to enroll your child/dependent in our program and look forward to an amazing semester/year ahead.


If you are in the Pittsburgh area, please complete this form.


If you are in the Boston area and Massachusetts, please DO NOT complete this form and contact Theresa Fortillus (tfortillus@girlsinclynn.org) for the correct form. 


NOTE: All program participants must complete this form every school year.

General Information












If not listed above
Child's Demographic Information

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Some funders require us to report on income information, however, we never share your individual income information with anyone.







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Please Move to Page 2 for Guardian and Emergency Contact Information.

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Parent/Guardian and Emergency Contact Information

For the purpose of this form, a guardian is an adult your child/dependent lives with, and a "Trusted Adult" is someone the child lives with or another person in your community you trust to pick them up from the program and/or serve as an emergency contact. 

Primary Parent/Guardian Information





please type out "Street" or "Avenue" as full words








Secondary Parent/Guardian Information







Trusted Adult





Please Move to Page 3 for Permissions and Liabilities Information.

Page 3

Permissions and Liabilities

Parents/Guardians: Please review the section below with your child/dependent to make sure they understand it is everyone's job to make SWSG safe and enjoyable for mentees and mentors. To make sure we all have a safe and enjoyable space, we agree to shared community guidelines. For decisions regarding attendance and participation in the program and special events, mentors and SWSG staff will consider the alignment of kids' behavior with the community guidelines outlined below.

Strong girls/kids are respectful.
  • I will respect and show kindness to all girls/kids, mentors, and adults even if we are different or disagree.
  • I will respect the building and materials by cleaning up after myself and following safe practices.
Strong girls/kids listen to others.
  • I will follow the directions of mentors and adults.
  • I will pay attention when others are speaking.
  • If I have something to say, I will wait my turn and I will not talk over someone else.
Strong girls/kids are leaders.
  • I will work hard to reach my goals and encourage others to do the same.
  • I will share my skills and help girls and mentors whenever I can.
  • I will speak up for myself and others.
  • If someone is bullying me or someone else, I will tell a mentor or an adult.
Strong girls/kids are team players.
  • When working with other kids, I will share my ideas and allow other kids an equal chance to share their ideas.
  • I will be willing to consider others' opinions and to compromise.
  • I will take turns and share with other kids.
Strong girls/kids do their best.
  • I will participate and try my best during SWSG.
  • Even if I am having a bad day or think I will not like an activity, I will try it.
  • I will be myself and I will share my talents with others.

Please read the following waivers and initial at the bottom to indicate your understanding and agreement.

I understand that as part of my child/dependent’s involvement in Strong Women, Strong Girls (SWSG) afterschool programming at the site indicated above (the "SWSG Program") my child/dependent may participate in activities including but not limited to, weekly programming, team building games, outdoor or active play, a journal writing exchange, and field trips using approved transportation. I authorize my child/dependent to participate in these activities. I agree that SWSG may end my child's participation in the SWSG Program at any time, and for any reason, at its sole discretion. I recognize that safe participation in the SWSG Program requires my child's attention to instructions provided by SWSG.

General Release:
I understand that while SWSG's volunteer mentors are trained to avoid and reduce the risk of injury, there is no way to fully eliminate the possibility that my child may be injured when participating in the SWSG Program. By allowing my child to participate in the SWSG Program, I hereby accept full and sole responsibility for any and all harm, injuries, and losses to my child or her property, except those caused solely by the gross negligence of SWSG. The undersigned on behalf of myself and my child, and our respective heirs, executors, administrators, personal representatives, and next of kin hereby release and forever discharge SWSG, and their officers, employees, and agents, from all liabilities, claims, demands, and causes of action which I, or my child, or their or my heirs, assigns, legal or personal representatives, or estates, can or may ever have arising directly or indirectly out of my child's participation in the SWSG Program, except those arising solely from the gross negligence of SWSG. I agree to indemnify, defend, and hold harmless SWSG, and their officers, directors, employees, and agents for any and all damages, liabilities, and losses arising directly or indirectly out of participation, except those caused solely by the gross negligence of SWSG. SWSG is committed to inclusivity, if you have questions about gender inclusivity, you can request the documentation be sent to you by email.
Emergency Medical Care:

In case of an emergency, I authorize SWSG to seek any medical assistance and treatment that my child/dependent may require, even if it is not possible for me to be consulted. I understand that if not fully covered by a medical insurance provider, I will be personally responsible for all costs incurred for the care provided.

Evaluation Process:

I understand that SWSG will evaluate the effectiveness of the SWSG Program and its impact on participants through surveys, arts evaluation, focus groups, observation, and other evaluation methods. I give permission for my child/dependent to participate in the evaluation process. I understand that SWSG may use the results of their evaluations, including any Materials (as defined below), for communications including reporting to funders, and that SWSG will not attach my child's name to any of their responses without permission. I understand that SWSG may communicate with my child's teacher, either in writing or verbally about their personal development. I understand that SWSG will keep confidential my child's health and academic information, in accordance with applicable U.S. federal and state privacy laws.

Third Party Services:

In connection with my child’s participation in the SWSG Program, I understand that my child may view content or gain access to services provided by third parties, such as Google and/or Zoom (“Third Party Services”), which may be subject to separate or additional terms and conditions.  I further understand that: (a) SWSG has no control over and is not responsible for the privacy policies or practices of such third parties; (b) such Third Party Services are provided by SWSG with no express or implied conditions, endorsements, guarantees, representations or warranties; (c) SWSG is not responsible or liable for any loss or damage of any sort incurred as a result of any Third Party Services; and (d) my child’s use of the Third Party Services is at my own risk.

Content:

I understand that SWSG may take photographs, videos, and other audio and/or visual recordings, in-person or virtually, of the children participating in the SWSG Program, including my child/dependent, in order to document, evaluate, and market the SWSG Program, and that such materials may be edited by SWSG in its sole discretion. I further understand that the virtual sessions may be video and/or audio recorded and links to these sessions will only be shared with the children and authorized mentors, staff, and volunteers of the SWSG Program.

 

In consideration of my child's participation in SWSG, I hereby grant and convey to SWSG, a perpetual, irrevocable, worldwide, unconditional, and exclusive right (including without limitation copyright) to use, distribute, reproduce, modify, display, print, and/or publish (i) my child’s name, likeness, image, voice, and/or appearance, (ii) written (e.g., testimonials), photographic, video, audio or multimedia materials made by my child in connection with the SWSG Program and other SWSG activities, and (iii) photographic images and video or audio recording of my child made by SWSG (collectively the "Materials"), in any media, including but not limited to photographs, video recordings, audiotapes, digital images in which the Materials may be in whole or in part, composite or distorted in character, sound or form, without restriction as to changes or transformations in conjunction with my child’s own or a fictitious name, or reproduction hereof. I agree that the Materials may be used for any purpose consistent with SWSG’s mission, including in news releases, advertisements, publications, marketing campaigns, media coverage, videos, websites, and any other promotional or educational materials compiled by or on behalf of SWSG.

 

I understand and agree that SWSG has and will have complete ownership of the Materials, and that I will not receive any compensation for the use of the Materials. I hereby release SWSG, and its affiliates, directors, officers, employees, agents, licensees, successors, assigns, and representatives, from any and all claims arising out of their use of the Materials as agreed to in this document, including without limitation any claims based on the right of publicity or privacy, misappropriation or misuse of image, and/or defamation, including liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form whether intentional or otherwise. I further hereby waive any future right to prior review of any use of the Materials.

 

Notwithstanding anything to the contrary herein, my child and I, on behalf of ourselves and our respective heirs, executors, administrators, personal representatives, and next of kin (collectively, "Releasers") hereby release and forever discharge SWSG and its affiliates, directors, officers, employees, agents, licensees, successors, assigns, and representatives, from any and all liabilities, claims, demands, and causes of action that Releasers might now or hereafter have arising directly or indirectly from the exercise of any rights granted hereunder.

 

 

I have read this SWSG Parent/Guardian Agreement prior to signing it, and I understand its contents, which is governed by and construed under the laws of the States of Massachusetts & Pennsylvania (excluding its conflicts of laws principles).

By entering your full name, you agree to the above sections and confirm your child's registration with Strong Women Strong Girls.