Weekend Family Workshop Enrollment Form Kidpower’s Weekend Family Workshop is our most comprehensive program, incorporating a wide range of personal safety techniques including awareness skills, boundary-setting and full-force self-protection skills with our head-to-toe padded instructors. This workshop is limited to 16 students, which allows each child personal attention and practice of every skill presented. Skills are taught in a safe, supportive environment to increase self-esteem and confidence in a way that is positive and enjoyable, not scary. Kidpower is endorsed by mental health professionals, law-enforcement officials, educators and parents. The Weekend Family Workshop is designed for children ages 7 to 12 years old. This class is limited to 16 students. Fees: Full tuition is $260 per child and includes a Kidpower Guide for Parents and Teachers, a Kidpower water bottle for the child and a DVD of the graduation to be used for reviewing the safety skills learned during the workshop. Discounts of $35 will be given if more than one child enrolls from the same family in the same class. Limited scholarships and payment plans may be available based on financial hardship. Payment by Visa, MasterCard and Discover is also available. To Register: A $100 non-refundable deposit must accompany the enrollment form below in order to reserve a place in the workshop. Please make checks payable to Kidpower. Spaces are reserved on a first-come, first-served basis. The $100 deposit will also hold a place on the waiting list if the class is full, but will be refunded if a space in the class does not become available. What happens on Friday of the workshop? From 6:30pm to 9:30pm, parents and other significant caregivers come to learn how to support and practice the skills which will be taught to the children. At least one parent or guardian per child is required to attend this training. As many adults as desired from a child’s life are welcome to participate for no extra cost. Children DO NOT attend this session of the workshop. What happens on Saturday of the workshop? From 9:00am to 1:00pm, trainers work with the children, without parents present, to introduce and practice the self-protection skills. What happens on Sunday of the workshop? From 9:00am to 1:00pm, the children’s training continues. From noon to 1:00pm, parents and other family members and friends, over the age of 13, have an opportunity to see what the children have learned during a special portion of the final class, their “graduation.”First Name of Person Enrolling Child:*Last Name of Person Enrolling Child:*Relationship to Child*Are you the legal guardian of the child?*YesNoChild InformationChild NameAgeBirth DateGenderMFNicknameSchool Attending & Grade Add another child Contact InfoAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Primary Phone Number*Other PhoneEmail* Best time(s) to reach youHow did you hear about Kidpower (check all that apply - Ctrl Click for multiple selections)Previous workshop attendeeInternet Search/WebsiteFriend/Family (please specify below)Safe PassageTherapist (please specify below)Other (please specify below)If therapist or "other", please specify.We LOVE referrals, please tell us which friend or family member referred you.EnrollmentDate of Enrollment*Wait list for next available classJune 8, 9 & 10, 2018 - FULLSeptember 7, 8 & 9, 2018 - FULLDecember 7, 8 & 9, 2018 - FULLMarch 1, 2 & 3, 2019 - FULL-ACCEPTING WAITLISTJune 7, 8 & 9, 2019NOTE: We will do our best to enroll your child(ren) in this class if there is an opening. We do recommend that you put your name on our wait list if you are interested in our upcoming dates. There may be last minute switches, particularly during cold and flu season, which may provide an opening. We will post the dates for our next four workshops in May. How many children are you enrolling?*Deposit only - $100Single Child - $260Two Children - $485Three Children - $710To pay in full choose the corresponding number of children you are enrolling. If you wish to only make a deposit, choose deposit only.Are there any health problems or special circumstances that we should know about?*YesNoIs your child currently taking any medication?*YesNoDoes your child(ren) have any learning, sensory, emotional or attention issues that may affect their participation in class?*YesNoIf you answered "yes" to any of the above questions, please explain here:* For the safety and well-being of your child, it would be beneficial for us to know if your child has experienced, been exposed to, or witnessed prior abuse or violence, including domestic violence. If yes, please briefly explain.* This information is secure and will remain confidential but if you would prefer to disclose offline, please call our office at (719) 520.1311.If yes to the above question, have these issues been addressed?*YesNoNot ApplicableDo you have specific safety concerns for your child?* Payment Method*Cash/CheckOnline PaymentCash or Check -Space is limited. Payment or other financial arrangement is required to hold your spot. Online - You will exit this website to check out on PayPal either with your PayPal account or with a credit card. Other - Check this box if you would like to apply for scholarship funding or if you have applied for Victim Compensation (or will apply.) Specify below which option and we will contact you. Total $0.00 A deposit (or other financial arrangement) is required to confirm your enrollment. Balance is due the first day of the workshop. Please make your checks payable to: Kidpower of ColoradoWe will now continue to PayPal to finalize your enrollment.