Black Girl Magic

Black Girl Magic After School Group provides a space for Black girls/young women to find support, connect with peers, and explore who they are! Those who identify as Black and/or African American, and are entering 8th – 10th grades in fall 2021, are invited to join group.

Black Girl Magic group will include a variety of activities, discussions, and field trips. Topics can include identity, self-esteem, self-care, body image, mental health, activism, and more. We will meet weekly to build community, and ultimately, celebrate our Blackness!

Black Girl Magic Fall Flier

Topics covered

cultural values
identity
self-care
self-esteem
leadership
resiliency

Activities

breaking down stereotypes
celebrating our crown (hair care)
partnerships with local, black-owned businesses
discussions
field trips
group bonding games and activities

Age group

Participants in 8th – 10th graders

Time & day

Fall group will meet on Thursdays, beginning September 9th, from 4 – 5:30 p.m. at the YWRC.

Have questions? Contact Elhondra via email or phone at 515.244.4901.

REGISTRATION:

After School Group Sign Up

Please complete this form to be considered for our After School Groups.

Days and times of each After School group are below. Please indicate with an X which After School Group(s) the participant is interested in and we will reach out to you shortly. / Los días y horas de cada grupo están a continuación. Indique con una X en qué grupo virtual está interesado el participante y nos comunicaremos con usted en breve.*
- 5th grade: Tuesdays/Martes, 3:15 – 4:45 p.m.
- 6th grades: Wednesday/Miercoles, 4 – 5:30 p.m.
- 7th grade: Mondays/Lunes, 4 – 5:30 p.m.
- 8th grades: Mondays/Lunes, 4 – 5:30 p.m.
- High School (9th – 12th grades): Wednesday/Miercoles, 4 – 5:30 p.m.
- Black Girl Magic (8th – 10th grades): Thursdays/Jueves, 4 – 5:30 p.m.
- Feminists United Now (FUN) / Fecha Y Horario se Determinara Pronto, (9th - 12th Grades) - Day and time TBD / Día y hora por determinar
- Mariposa (7th – 10th grades): Thursdays/Jueves, 4 – 5:30 p.m.
Participant Name / Nombre del Participante*
First Name / el Primer Nombre Last Name / el Apellido
Participant Date of Birth / Fecha de Nacimiento*
Name of Participant's School / Escuela de Participante*
Grade of Participant / Grado*
Caregiver Name / Nombre del cuidador*
First Name / Primer Nombre Last Name / Apellido
Caregiver Email / Correo electrónico del cuidador
Enter Email / Ingrese Correo Electrónico Confirm Email / Confirme Correo Electrónico
Caregiver Phone / Teléfono del cuidador
Please check preferred method of communication for monthly group updates / ¿Como prefería recibir comunicación de las actualizaciones mensuales?:
- Email / Correo Electrónico
- Phone / Correo
Address / Dirección
Street Address / Dirección Address Line 2 City / Ciudad State / Estado Zip Code / Código Postal Country / País
Race / Raza*
- Black / African American / Negra / Afroamericana
- Asian / Asiática
- Native Hawaiian / Pacific Islander / Nativa Hawaiana / otra Isleña del Pacífico
- White / Caucasian / Blanca / Caucásica
- American Indian / Native Alaskan / India Americana / Nativa de Alaska
- Other / Otras / Múltiples razas
Is the participant Latina / Latinx? / ¿Es latina la participante?*
- Yes / Si
- No / No
Does the participant identify as LGBTQIA+? / ¿La participante se identifica como LGBTQIA +?*
- Yes / Si
- No /No
- Unknown / Prefer not to answer / Desconocida /Prefiere no responder
Does the participant utilize the free/reduced lunch program? / ¿Utiliza el participante el programa de almuerzo gratis/reducido?*
- Yes / Si
- No / No
Does the participant need a ride TO the YWRC for this program? (The participant must be within a 7-mile radius of the YWRC to receive transportation.) / ¿El participante necesita que lo lleven al YWRC para este programa? (El participante debe estar dentro de un radio de 7 millas del YWRC para recibir transporte).*
- Yes / Si
- No / No
Does the participant need a ride HOME from this program? (The participant must be within a 7-mile radius of the YWRC to receive transportation.) / ¿El participante necesita que lo lleven a CASA de este programa? (El participante debe estar dentro de un radio de 7 millas del YWRC para recibir transporte).*
- Yes / Si
- No / No
I give my child permission to attend the YWRC Programs and any field trips planned and will allow my child to be transported by YWRC Staff/Volunteers. / Le doy a mi hija permiso para asistir a los programas de YWRC y cualquier excursión planeada y permitiré que mi hija sea transportada por el personal/voluntarios de YWRC.*
- Yes / Si
- No / No
I understand that the YWRC is not responsible for any stolen or lost personal belongings. In the event of accident, injury, or sudden illness and I cannot be reached; I give my consent for the YWRC staff to secure proper medical treatment. I agree to be responsible for all medical expenses. / Entiendo que el YWRC no es responsable de ningún artículo robado o perdido. En caso de accidente, lesión, o enfermedad repentina y no puedo ser localizado; doy mi consentimiento para que el personal de YWRC obtenga un tratamiento médico adecuado, para mi hija. Acepto ser responsable de todos los gastos médicos.*
- Yes / Si
- No / No
I give permission to the YWRC to use any photographs or video tapes taken of my child while participating in the program to use for promotional activities of the program. / Doy permiso al YWRC para usar cualquier fotografía o video grabado de mi hijo mientras participa en el programa para usarlo en actividades promocionales del programa o la escuela.*
- Yes / Si
- No / No
May the staff from the YWRC may contact you or your student for follow-up through their high school graduation? / ¿Puede el personal de YWRC comunicarse con usted o su estudiante para seguir el progreso hacia la graduación de la escuela secundaria?*
- Yes / Si
- No / No
YWRC conducts periodic surveys with our clients to measure progress and to make program quality improvements. / YWRC realiza encuestas periódicas con nuestros clientes para medir el progreso y mejorar la calidad del programa.
Caregiver Signature / Firma del cuidador*
Signature Date / Fecha*
MM
DD
YYYY
I assume all responsibility for any accidents or injuries that may occur, and release the facilitators and Young Women’s Resource Center employees of all liability. In case of accident, injury or sudden illness and I cannot be reached, I request that necessary medical care be instituted. Our physician/dentist may be contacted in case of medical treatment or as necessary and is authorized to release requested information as needed. The caregiver/guardian is responsible for all medical expenses. / Asumo toda la responsabilidad por cualquier accidente o lesión que pueda ocurrir, y libero a los facilitadores y los empleados del Centro de Recursos de Mujeres Jóvenes de toda responsabilidad. En caso de accidente, lesión o enfermedad repentina y no puedo ser contactado, solicito que se instituya la atención médica necesaria. Nuestro médico/dentista puede ser contactado en caso de tratamiento médico o como sea necesario y está autorizado a divulgar la información solicitada según sea necesario. El/la cuidador(a)/guardián es responsable de todos los gastos médicos.
Participant's Doctor / Doctor de Participante*
Participant's Doctor's Phone / Doctor de Participante Teléfono:*
Participant's Dentist / Dentista de Participante:*
Participant's Dentist's Phone / Participant's Dentist / Dentista de Participante Teléfono*
Hospital Preference / Preferencia del Hospital*
Emergency Contact, Name and Phone Number, Relation to Participant / Contacto de Emergencia, Nombre y Número, Relación:*
Emergency Contact, Name and Phone Number, Relation to Participant / Contacto de Emergencia, Nombre y Número, Relación:*
Does the participant have any allergies? / ¿La participante tiene alguna alergia?*
- Yes / Sí
- No / No
If yes, what allergies? / Si contestó Sí, ¿qué alergia?
Medication - name and dosage. (Please note that YWRC Staff is unable to administer medication. This information is for emergency personnel only.) / Medicamentos - nombre y dosis (Tenga en cuenta que el personal de YWRC no puede administrar medicamentos. Esta información es para personal de emergencia solamente.)
Health Concerns / Preocupaciones de Salud
Health Insurance Name / Nombre del Seguro de Salud
Insurance Number / Número de Seguro
I have answered these questions to the best of my knowledge. If I have any questions or concerns, I will speak with the group facilitator. / He contestado estas preguntas a mi leal saber y entender. Si tengo alguna pregunta o inquietud, hablaré con la lider del grupo.
Caregiver/Guardian Signature / Firma de Cuidador(a)/Guardián*
Date*
Date Format: MM slash DD slash YYYY

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