EIN: 81-4391734

(360) 878-2043

Olympia, WA

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Programs
Volunteer
- Board Member Application
Donate
Events
- Solstice Retreat
Blog
Resources
About

Week-Long CMCB Camp Registration

Conscious Minds Conscious Bodies™

WEEK-LONG CAMP
July 12 - 16, 2021
9:30 AM - 4:00 PM

CAMP LOCATION
The Coach House
211 21st Ave SW
Olympia, WA 98501

Driving Directions

TO REGISTER:

Complete the Camp Registration form on the right, including the Pre-Camp Questionnaire.
Make your $100 nonrefundable deposit to reserve your space.

APPLYING FOR A SCHOLARSHIP?
Please complete our Scholarship Questionnaire to be considered for a scholarship for one of our Camps, then return to this page and complete your registration.

Scholarship Questionnaire

QUESTIONS? Call or Email Kristen
(360) 878-2043
hello@empowerment4girls.com

Camp Registration

* Indicates required field

Choose One: Separate Registration For Each Camp Required *

July 12-16, 2021

Parent or Guardian *

First

Last

Person Attending *

First

Last

Age & Birth Date *

Address *

Line 1

Line 2

City

State

Zip Code

Country

If no Line 2, please enter x

Email *

Phone Number *

Pre-Camp Questionnaire

Please take a moment and answer the following questions. All information provided will be stored securely. Personal information will only be shared with Empowerment 4 Girls Camp staff and pre-screened camp volunteers, as needed.
Click the (?) for detailed instructions for each question.

1. Dietary Restrictions *

Please list all dietary restrictions if any? (Gluten/dairy free, etc.) If none, please enter NONE

2. Food Preference *

Vegan Vegetarian Meat Eater

What is your food preference?

3. Does your child have any medical conditions or other health restrictions? Are they on any medications? *

Please let us know about any medications, medical or health conditions we need to be aware of. If none, please enter None.

4. What is your Annual Household Income? *

$0-$16,910 $16,911-$25,750 $25,751-$34,590 $34,591-$43,430 $43,431-$51,500 $51,501-$60,340 $60,341-$69,180 $69,181-$77,250 $77,251-$86,860 $86,861-$103,770 $103,771-$117,030 $117,031-$130,290 $131,291-or more

Annual Household Income includes all income made by members of your household.

5. How many people are supported by your Annual Household Income? *

2 3 4 5 6 7 8

Include all people who are supported by your Annual Household Income.

6. Racial Makeup of Household - Choose all that apply *

Alaska Native American Indian Asian Black Hispanic White

Providing this optional information supports our fundraising and program evaluation efforts.

7. Does your child exhibit any behavioral, emotional or developmental challenges? *

Anxiety Depression Suicidal Thoughts or Expression Aggression Toward Others Self-Harm Learning Disabilities None of the Above

Please let us know if your child has experienced any of the following:

7a. Please explain above choices: *

Please explain your selection of the above items. For example, if you choose Learning Disabilities, please indicate what these are.

8. How do you think this camp will benefit your child and your household? *

Also let us know if you think there will be benefits to others in your household.

9. What are some of the expectations you have in your child attending this camp? Choose any that apply. *

Positive Body Image Become More Empowered Increase Confidence Puberty/Menstruation Education Gender Identity/Sexual Orientation Building Healthy Relationships Consent/Boundaries Resiliency Stress Reduction Spiritual Growth Connecting with Others Social Media Awareness Needed a Place for My Child Other - Please Explain Below:

9a. Explain other expectations *

Please explain the other expectations you had in choosing this camp for your child.

Is this child in the foster care system? *

Payment

A 501(c)(3) Nonprofit Corporation
EIN: 81-4391734
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Contacts

Kristen Rubis
Program Director
360-878-2043
hello@empowerment4girls.com

Jeannine Anderson
Development Director
360-463-6405
admin@empowerment4girls.com

Phil Hyde
Operations Director
p.hyde@empowerment4girls.com

Mailing Address

9134 Steamboat Island Rd NW
Olympia, WA 98502

Nondiscrimination Policy: Empowerment 4 Girls does not discriminate on the basis of race, ethnicity, religion, gender, gender identity or expression, sexual orientation, disabilities, age, status as a veteran, national origin, or any other protected classes, specifically with regard to participants in our programs, employees, board members or volunteers.