Women's Teenpower Enrollment Form This four-hour workshop for young women ages 13-18 provides a safe and supportive environment for participants to learn and practice emotional and physical safety techniques. Students learn skills for healthy relationships and to set boundaries in uncomfortable or unsafe situations, including peer pressure, verbal attack and harassment. This program also uses a head-to-toe padded instructor to give students the opportunity for realistic and safe practice of simple and effective self-defense. Our services provide a professional training that most participants tell us is life changing. This class is limited to 12 students. Fees: The workshop fee is $110 per teen. Discounts of $10 will be given if more than one teen enrolls from the same family in the same class. Payment plans and scholarships are available; we also accept MasterCard, Visa and Discover. If you need scholarship support, please enclose a brief letter about the situation and a payment for the amount you can afford.To Register: Please send the enrollment form with your payment to Kidpower, 10 Boulder Crescent, Suite 100, Colorado Springs, CO 80903. We limit our workshop size and must have your deposit in order to reserve your spot.First Name of Person Enrolling Teen:*Last Name of Person Enrolling Teen:*Relationship to Teen*Are you the legal guardian of the teen?*YesNoTeen InformationTeen NameTeen AgeBirthdateSchool Attending & Grade Add another teen 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*August 25, 2018 - FULLNovember 3, 2018 - FULLFebruary 9, 2019Waitlist for next available classNOTE: 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?*Single Child - $110Two Children - $210Three Children - $310Are there any health problems or special circumstances that we should know about?*YesNoIs your teen currently taking any medication?*YesNoDoes your child have any learning, sensory, emotional or attention issues that may affect their participation in class?*YesNoIf you answered "yes" to any of the questions above, please briefly explain:* For the safety and well-being of your child, it would be beneficial for us to know if your teen has experienced, been exposed to, or witnessed prior abuse or violence, including domestic violence. If so, please briefly explain:* This information is secure and 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 teen?* 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 with either 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 day of the workshop. Please make your checks payable to: Kidpower of ColoradoWe will now continue to PayPal to finalize your enrollment.