POM Girls St. Paul Power of Me for Girls Grades 4-5 and 6-8 St. Paul Participant InformationParticipant Name* First Last Birthdate* Grade entering in 2018-19 school year*4th grade5th grade6th grade7th grade8th gradeHow did you hear about The Power of Me?From a friendFrom schoolFrom social worker or therapistFacebookFlyerWebsiteFriend's nameSocial worker / therapist's nameContact InformationParent / Guardian Name* First Last Phone*Email* Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact InformationEmergency Contact Name* First Last Emergency Contact Relationship to Child*Emergency Contact Phone Number*Payment InformationPayment Options*Pay in full at first workshop via check ($175 due at first workshop)Pay in full for membership via credit / debit card - $195 due at time of purchaseMonthly membership payments - 7 monthly payments of $39 via credit cardIndividual workshop - $452 individual workshops - $903 individual workshops - $135Month attending
