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Empowerment and Therapy

To sign up for Empowerment and Therapy programs, please contact us at 515.244.4901 . This includes After School groups, Hit the Ground Running, Mariposa, Summer Programs, Therapy, Lotus and Connections.

Young Moms

To sign up for Young Moms programs, please complete the registration form below or contact us at 515.244.4901. This includes Pregnancy & Childbirth and Parenting & Life Skills groups.

Program Registration

Intake and Registration form.

Step 1 of 5 - Guardian Information

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Type of Program*
- Young Moms
- Childbirth Education
- Parenting and Life Skills
Guardian Name
FirstLast
Guardian Address
Street AddressAddress Line 2CityStateZIP Code
Guardian Phone
Guardian Email

Client Name*
FirstLast
Client Address*
Street AddressAddress Line 2CityStateZIP Code
Cell Phone
Email*
Enter EmailConfirm Email
Date of Birth*
Gender*
- Female
- Transgender
Race*
Are you Hispanic*
- Yes
- No
What school do you attend?*
Grade in School*
Highest Completed Education*
- GED Program
- Vocational Training
- College/University
- 9th Grade
- 10th Grade
- 11th Grade
- 12th Grade
- Other
High School Name*
Highest Grade Completed*
Do you participate in the free / reduced lunch program?*
- Yes
- No
Do you require transportation to/from the YWRC program(s)?*
- Yes
- No
Marital Status*
- Single
- Married
- Living with significant other

Children's Names, Ages, Dates of Birth and/or Due Date*
Does your child(ren) have any allergies?*
- Yes
- No
- Child has not been born yet
What allergies and which children?
Programs you are enrolling in (you may select more than one)*
- Life Skills for Young Moms
- Better Beginnings Doula Program
- Childbirth Education
- Individual Support Program
How much money do you make in a year?*
- $0 - $5,415
- $5,416 - $9,424
- $9,425 - $10,829
- $10,830 - $13,429
- $13,430 - $16,137
- $16,138 - $18,844
- $18, 845 - $19,927
- $19,928 - $21,559
- $21,560 - $32,389
- $32,390 - $43,319
- $43,320 - $54,149
- $54,150 - higher
Are you employed?*
- No
- Yes, Full-time
- Yes, Part-time

Doctor Name*
FirstLast
Doctor Phone*
Dentist Name*
FirstLast
Dentist Phone*
Hospital Preference

Emergency Contact Name*
FirstLast
Emergency Contact Phone*
Emergency Contact Relationship*
Child's Medication (list name & dosage)
Mother's Medication (list name & dosage)
List Child's Allergies & Health Concerns
List Mother's Allergies & Health Concerns
Health Insurance
Insurance Number
I understand that the YWRC is not responsible for any stolen or lost personal belongings. I understand the YWRC is not responsible for any personal injuries that may occur to my child(ren) and/or myself during participation in programming. In the event of accident, injury, or sudden illness, I give my consent for the YWRC to secure proper medical treatment and agree to be responsible for all medical expenses. I authorize the YWRC to provide basic demographic information to the United Way of Central Iowa who provides funding for this program. I understand staff from the YWRC may contact me or my student with follow-up through high school graduation.
I authorize the YWRC to provide basic demographic information to the United Way of Central Iowa who provides funding for this program.*
- Yes
- No
I give the YWRC permission to provide transportation for me and/or my child(ren).*
- Yes
- No
I give the YWRC staff/volunteers permission to provide child care for my child(ren).*
- Yes
- No
I give permission to the YWRC to use and photographs or video tapes taken of me and/or my child(ren) while participating in the program to use for promotional activities of the program or school.*
- Yes
- No
How did you hear about us?*
- family member
- guidance counselor
- current YWRC participant
- school
- other
I have answered these questions to the best of my knowledge. If I have any questions or concerns, I will speak with the program facilitator.
Parent / Guardian Signature*
Untitled
Untitled
- First Choice
- Second Choice
- Third Choice
Email
This field is for validation purposes and should be left unchanged.

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Young Women's Resource Center

818 5th Avenue
Des Moines, IA 50309
(515) 244-4901
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