Registration

Columbiana GLOW Registration

We are a pregnancy prevention program that aims to increase girls' sense of self-esteem, reliance, and expression to encourage investment in their personal development and goals. We believe girls who know themselves, believe in themselves, and can express what they want make safer and healthier choices.

* Indicates required field

Participant's Legal Name *

First

Last

Participant's Preferred Name *

Address *

Line 1

Line 2

City

State

Zip Code

Country

Name of Parent/Guardian *

First

Last

Parent/Guardian Phone Number *

Parent/Guardian Email *

school *

Grade Entering Fall of 2025 *

Date of Birth *

Shirt Size *

Any Allergies, Food Intolerances, and/or Medical Conditions we should know about? *

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 *

Consent Given Consent NOT Given

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)

How did you learn about glow? *

How can we help? Please list any topics/concerns with raising teenage girls that you would like more information on as a parent/guardian. * *

Submit

Columbiana GLOW Registration

Columbiana GLOW Registration

Mission

MAILING ADDRESS
FOR ALL LOCATIONS

Columbiana GLOW Registration

​Columbiana GLOW Registration

Mission

​MAILING ADDRESS​FOR ALL LOCATIONS

Columbiana GLOW Registration

MAILING ADDRESS
FOR ALL LOCATIONS