Project Connect 209 Student Registration

Year 1 Participant Application

Able Works: Project Connect 209

1. PARTICIPANT INFORMATION (Please Type Clearly)

PARTICIPANT NAME: (First, Middle Initial, Last)

DATE OF BIRTH

Date

AGE

SELECT ONE

MALE FEMALE

ADDRESS: (Number, Street, and Apt or Suite No.)

ADDRESS: (City, State, Zip)

ETHNICITY

YOUTH CELL PHONE

YOUTH E MAIL

example@example.com

Does your child have any physical limitations we should know about? YES

NO Brief Description:

Brief Description

Does your child have any food allergies we should know about? YES

NO Brief Description:

Brief Description

CIRCLE ONE

2. PARENT/GUARDIAN INFORMATION (we will use this contact in case of emergency)

A. PARENT/GUARDIAN NAME: (First, Middle Initial, Last)

RELATIONSHIP TO YOUTH

PARENT/GUARDIAN CELL PHONE

PARENT/GUARDIAN E MAIL

example@example.com

3. PARENT'S CONSENT and YOUTH ASSENT

[Particpant's Name] is invited to participate in the Able Works SRAE Teen Intervention Project where he/she will learn relationship skills, that will help him/her with youth development in but not limited to life skills, healthy relationships, dating violence, sexual delay and sexual risk avoidance. This program consists of 12 lessons and could take 8 sessions to complete, with each lesson taking from 21 mins to 57 mins. Lesson length and completion of the project is dependent on the community organization hosting the classes. During that time your youth will be invited to complete an Entry and Exit Survey before and after the program. The surveys ask about healthy relationships and what the youth will be learning in the program. Participation in the program and completing the surveys is completely voluntary,whichmeans that there are no consequences if your youth does not want to join the program. We will keep the information we collect confidential. We will not use any names on oral or written reports or presentations. This form is the only one that has your information and we will keep it in a locked cabinet, within a locked office in the main offices of Able Works. Nobody except the program manager and project analyst will have access to this form.

Enter participants name here

If you agree to let your youth participate, please read this statement and sign below. My signature here means that I give my consent to allow my child/ward to participate in the Able Works SRAE Teen InterventionProjectinorder to learn healthy relationship skills:

Parent/Guardian Signature

Clear

Date

Sometimes program staff take photos, recordings or films of participants during the program. These photos may be used for program advertisement and/or in presentations or reports. If you agree to have the photo of your youth taken during the program review the statement below and sign.

My signature here means that I authorize Able Works to take a photo, video, or recording of my youth during the program and to use the photo for program marketing purposes, or during presentations or reports.

Parent/Guardian Signature

Clear

Date

I understand what the Able Works SRAE Teen Intervention Project program is about and what to expect if I join in. I also understand that my participation is voluntary and that the program staff will keep my participation confidential. I was given the opportunity to ask any questions about the program. My signature below means that I agree to participate.

Participant (Youth) Sign or Print/Type in Full Name

Clear

Date

FOR USE BY ABLE WORKS PERSONNEL ONLY