Columbiana Registration

Columbiana Glow Registration

A free program developed to help girls build their sense of self-esteem, self-expression and self-reliance.

* Indicates required field

Name *

First

Last

Email *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Grade *

Current Age *

Name of Parent/Guardian *

First

Last

Parent/Guardian Phone Number *

Parent/Guardian Email *

MEDICAL CONSENT *

Medical and Liability Release for GLOW

I understand that if medical intervention is needed, every attempt will be made to contact the persons listed on this form. In the event I cannot be reached in an emergency, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.

I understand all reasonable safety precautions will always be taken by The Way Station and its agents. I understand the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold The Way Station, its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

Photo Release *

Photo Consent

I give permission for photos of my child to be posted or shared (on the The Way Station web site, Facebook, Instagram, Newsletter, and/or Newspaper)

Submit

Columbiana GLOW

Columbiana Glow Registration

Mission

MAILING ADDRESS
FOR ALL LOCATIONS

Columbiana GLOW

​Columbiana Glow Registration

Mission

​MAILING ADDRESS​FOR ALL LOCATIONS

Columbiana Glow Registration

MAILING ADDRESS
FOR ALL LOCATIONS