Empowerment Workshop – 2023

Space is LIMITED! Register by March 3rd via the form below or contact Irma at 515.244.4901 or email to receive a printed copy.

5th – High School students* in Des Moines and surrounding areas are invited to join us for Empowerment Workshop! Empowerment Workshop is free. Lunch is included and transportation is offered to those within 7 miles of the YWRC.

TUESDAY, MARCH 14th: 5th – 7th Grades
WEDNESDAY, MARCH 15th: 8th – High Schoolers

Questions about registration or the workshops? Email Irma here.

*Persons who have been socialized and/or identify as female; non-binary and gender fluid folks are welcome.

Empowerment Workshop Registration Form / Registro del Taller de Empoderamiento

Please complete this registration form to be considered for our Empowerment Workshops.

Participant Name / Nombre del Participante*
First Name / el Primer Nombre Last Name / el Apellido
Participant Birthday / Fecha de Nacimiento*
Participant Age / Edad del Participante
Name of Participant's School / Escuela de Participante*
Grade Participant is Going Into / Grado entrando*
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
Address / Dirección
Street Address / Dirección Address Line 2 City / Ciudad State / Estado Zip Code / Código Postal Country / País
Emergency Contact Name / Contacto de emergencia nombre*
First Last
Emergency contact phone / Contacto de emergencia teléfono*
Participant Allergies / Alergias del Participante*
Does the participant need a ride TO the YWRC for the event (within a 7-mile radius of the YWRC)? / ¿La participante necesita transportación al evento? (Se proporciona transporte para aquellos dentro de un radio de siete millas del YWRC.)*
- Yes / Si
- No / No
Pick up address / Dirección en donde la recogemos
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Does the participant need a ride home FROM the event? (Within a 7-mile radius of the YWRC) / ¿La participante necesita transportación del evento a su casa? (Se proporciona transporte para aquellos dentro de un radio de siete millas del YWRC.)*
- Yes, same as "Pick Up Address" / Si, marque aquí sí es la misma dirección
- Yes, new drop off address / Si, dirección en donde la dejamos
- No / No
New drop off address / Dirección en donde la dejamos
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
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
I give my child permission to attend the Young Women’s Resource Center’s (YWRC) Empowerment Workshop and allow my child to be transported by the YWRC staff/volunteers. 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. I assume all responsibility for any accidents or injuries that may occur and release the facilitators and YWRC 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. / Yo le doy permiso a mi hija para asistir al taller de empoderamiento de YWRC y permito que mi hija sea transportada por el personal o voluntario de YWRC. Entiendo que el YWRC no es responsable por ninguna pertenencia personal robada o perdida. En caso de accidente, lesión o enfermedad repentina y no se me pueda localizar, doy mi consentimiento para que el personal de YWRC obtenga el tratamiento médico adecuado. Acepto ser responsable de todos los gastos médicos. Asumo toda la responsabilidad por cualquier accidente o lesión que pueda ocurrir y libero a los facilitadores y a los empleados del YWRC de toda responsabilidad. En caso de accidente, lesión o enfermedad repentina y no se me pueda localizar, solicito que se instituya la atención médica necesaria.
- 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
Caregiver Signature / Firma del cuidador*
Signature Date / Fecha*
MM
DD
YYYY

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Empowerment Workshop – 2023

Empowerment Workshop Registration Form / Registro del Taller de Empoderamiento

Related Programs

After School Groups

Black Girl Magic

Mariposa