APPLICANT INFORMATION

PARENT/GUARDIAN INFORMATION

Emergency Contact

PARTICIPANT HEALTH INFORMATION

LIABILITY WAIVER

The participant noted below, and her parent/legal guardian shall save PowerPlay NYC, Inc. (“PowerPlay”) and all other program providers and their respective officers, directors, employees, and agents harmless against any and all injury, loss, or damage and any and all claims for injury, loss, or damage or whatever nature resulting from the student’s participation in the SuperSTARS Leadership Academy. With my signature below, I hereby give my permission to PowerPlay and the program providers to give consent on my behalf in the event of the need for the emergency administration of medical treatment which any of the Program Providers, in its sole discretion, believes to be necessary and appropriate, including, without limitation, treatment by trained First Aid personnel, EMTs, First Responders, Paramedics and Emergency Room Physicians. In consideration of the Program Providers permitting my child to participate in the STARS Series activities and programs, I hereby release, discharge and agree to indemnify and hold harmless the Program Providers and their directors, organizers, sponsors, coaches, staff, volunteers and agents from any and all claims, liabilities or caused of action arising out of such treatment and with respect to the exercise of its judgment in this regard. I further attest that I have disclosed all vital and important health information (allergies, medications and medical limitations on activities) which would be necessary for the proper care of my child. I agree to pay, and to assume responsibility, for all medical expenses incurred in the treatment of my child.

PHOTO RELEASE

I give PowerPlay NYC, Inc. and all other program providers permission to use my daughter’s photo in materials that promote any of the Program Providers. This may include brochures, newspapers, the Internet, magazines, or television. 

Hello Insight Waiver

Dear Parent/Guardian,
This waiver is for your child participating in the SuperSTARS Leadership Academy. In order to ensure PowerPlay programming is of the highest quality and has a positive impact on your child(ren), we engage in ongoing evaluation and quality improvement efforts. As a participant, your child(ren) will be invited to fill out an online or paper survey at the beginning and end of each program cycle. These surveys measure the impact of the program on your child’s development and captures her experiences within the program, allowing us to make critical improvements to meet their needs. How will your child participate in the survey? The surveys take about 20 minutes to fill out and will typically occur during normal program hours when the program is in session. Your child will be invited to complete the survey in a group setting with paper or online with a link to the survey to complete the survey on their own. Participation is completely voluntary. What are the benefits to taking the survey? Your child will become more reflective about their skills and behaviors. Reflection is a key developmental skill that has been shown to lead to a wide-range of benefits for young people. Additionally, as the adult staff learn more about your child’s interests and experiences in the program, they will be able to tailor activities to meet their needs. How is my child’s confidentiality protected? All information obtained will be kept confidential and used by staff solely to increase the quality of the curriculum and continue to improve the program and support your child’s individual needs. All data are gathered and analyzed through an online platform called Hello Insight. Your child’s name will not be associated with data in Hello Insight. Data within this platform are kept confidential in a secure database and Hello Insight/PowerPlay NYC will never use your child’s name for any reason.  All data displayed through this system will highlight combined or group results. If you have any questions regarding this process or the surveys themselves, you may contact our programs team at 646-619-3808. 
You may also contact Hello Insight at support@helloinsight.org.If you agree your child can take the survey, please sign below and return this form. 

Agreement I have received and read this form. I agree to allow my child(ren) to participate in filling out surveys within this program.

APPLICANT QUESTIONS:

SSLA Peer Coaching

This program allows SSLA participants the opportunity to gain real work experience by matching with adult PowerPlay STARS Series coaches for 6 months. Participants will be able to develop their coaching skills and serve as mentors to elementary and middle school girls in our STARS Series After School program alongside PowerPlay NYC’s STARS Afterschool Series coaches. 
Participants will receive training and will develop and execute their lessons in session. Finally, Peer Coaches will sharpen their public speaking, leadership, and social awareness skills. This program requires a 6 month commitment. Upon completion, participants will receive a $500 stipend.

I agree to the above commitment and therefore agree to the terms and conditions of the SuperSTARS Leadership Academy Peer Coach Program and promise to commit to the best of my abilities.

Mentorship Program

The SuperSTARS Leadership Academy (SSLA)  Mentorship Program will pair SSLA participants with professional women across business sectors and at various points in their careers. Mentors will be expected to attend monthly Mentor Meet Ups over an eight-month period where they will spend part of the time, one-on-one with their mentee and the other time engaging in college and career readiness workshops with the group.

I agree to the above commitment and therefore agree to the terms and conditions of the SuperSTARS Leadership Academy Mentorship Program and promise to commit to the best of my abilities.