Project HEARTS - Program Application (FY22)

Project HEARTS Participant Application

General Participant Information
Participant First Name:*
Participant Middle Name:
Participant Last Name:*
Age:*
*Participants must be between the ages of 14 - 19 years old to participate.
Date of Birth:*

MonthDayYear
**Supporting evidence may be requested to verify DOB for funding purposes.
Grade Level:*
**Participants must be in at least 9th grade (or going into 9th grade if currently out for Summer) to participate.
Address (must be a CA resident to participate)*

Street Address

CityMust be a CA resident

Zip Code
Student Cell Phone Number:*
*used for primary contact and to send out program reminders
Student "School" Email:*
*used to send out Gift Cards and other program information
Student "Personal" Email:*
*used to send out Gift Cards and other program information
Alternate Phone Number:
*Optional* Please enter a home or alternate phone number if you have one.

PARENT/GUARDIAN INFORMATION

(We Will Use This Contact in Case of Emergency)
Parent/Guardian Full Name:*
Relationship to Participant:*
Parent/Guardian Cell Phone:*
Please enter a valid phone number.
Parent/Guardian Home Phone:
Please enter a valid phone number.
Parent/Guardian Email:
PHOTO RELEASE:

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. Names and personal information will NOT be disclosed. If you agree to have a photo or recording taken during the program, review the statement below and sign.

My signature here means that I authorize Project HEARTS through EntreNous Youth Empowerment Services to take a photo, video, or recording of the above-named youth participant and to potentially use it for program marketing purposes, presentations, or reports.
PHOTO RELEASE: Youth Participant Signature

Clear
Date:

MonthDayYear
Today's Date
PHOTO RELEASE: Parent/Guardian Signature

Clear
**Additional Parent/Guardian Signature Needed for Youth Under 18
Date:

MonthDayYear
Today's Date
For youth under 18 years old, a parent/guardian must review the PARENT FORM available in English and Spanish.

Parents/guardians DO NOT need to return the parent form if they consent to let their youth's participation.

Program and Evaluation Participation Assent Form for
Subjects Ages 16 to Age of Majority

You are being invited to participate in a research study. Participation in this research study is voluntary. The Department of Health and Human Services is sponsoring this research study. This research study is called Project HEARTS (Healthy Exploration of Adolescent Relationships Training and Strategies). EntreNous Youth Empowerment Services will be offering Project HEARTS in a virtual Zoom setting.

Project HEARTS encourages healthy decision making, relationship skills, promotes family planning and prevention, and asks young people to be actively engaged in their own education and wellbeing. This program was designed to be implemented over 2 weeks to youth between the ages 16-19 years old. The program will be held over 2 weeks on Tuesdays-Thursdays, for a total of 6 days and 12 program hours. About 240 youth subjects will participate in this study. The purpose of this research study is to track the implementation and outcomes of the Project HEARTS program.

WHAT WILL HAPPEN DURING THE STUDY?

Participation in this program is voluntary. This program is paired with a research study. As part of that process, you will be asked to complete a short survey at the beginning of the program to help us learn more about who we are reaching. At the end of the program, you will be asked to complete another short survey to give us feedback on the program. Both surveys are voluntary, and you can choose not to take them or to skip any questions you wish.

Both of these surveys will be anonymous and your name will not be on either form.

If you have any questions about your participation, you or your parent/legal guardian can contact the study investigator listed on the first page of this form.

RISKS OF STUDY PROCEDURES

Discomfort with Questionnaires

If you find any part of the surveys in this study upsetting, you do not need to answer any questions that you are not comfortable with. Though it is always better to have fully completed questionnaires, you do not need to answer any questions that make you feel uncomfortable.

Loss of Confidentiality

There is a risk of loss of confidentiality. This risk minimized in the following ways:

The survey will not include any identifying information. Subjects will be assigned a unique ID number which will appear on their surveys.

WILL WHAT I SAY BE KEPT PRIVATE?

Your record of participation and surveys done for this study will be seen by the study investigator, and other people who run and manage the study. People who make sure that the study is being done the right way may also see it. If the information about the study is sent anywhere else, it will not have your name on it.

WHAT IF I DON'T WANT TO BE IN THIS STUDY?

You do not have to be in the study if you do not want to. You can also decide to start the study now and then stop being in it at any time. No one will be mad at you if you decide not to be in the study or decide to stop being in it later.

ASSENT

Please check below whether or not you willingly agree to participate in Project HEARTS and the research study. Then sign, date, and submit.
I have read and understand the description of the Project HEARTS program and the research study, and:*

I willingly agree to participate in the program and the studyI do not agree to participate in the program and the study
You selected "I do not agree to participate in the program and the study"

Thank you for your interest in Project HEARTS.

An important note: Due to your selection in the previous question "I do not agree to participate in the program and the study", unfortunately, you are NOT ELIGIBLE to receive any materials which include: curriculum/ participant workbook, swag, or incentives (i.e. daily gift cards, Grand Prize raffle, and Refer-A-Friend gift card offer) while participating in the workshops.

Please feel free to change your answer if you’d like.
Youth Participant's Name:*

First NameLast Name
Youth Date of Birth:*

MonthDayYear
Youth Participant's Signature*

Clear
Today's Date*

MonthDayYear
Adult Participant's Name:*

First NameLast Name
Adult Participant's Signature:*

Clear
Today's Date:*

MonthDayYear
Should be Empty:

Project HEARTS Participant Application

PARENT/GUARDIAN INFORMATION