PARTICIPANT APPLICATION PC209

Year 1 Participant Application

Youth for Christ: Project Connect 209

1. PARTICIPANT INFORMATION (Please Type or Print Clearly)

PARTICIPANT NAME: (First, Middle Initial, Last)*

DATE OF BIRTH*

Date

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

ADDRESS: (City, State, Zip)*

AGE*

MALEFEMALE

ETHNICITY*

YOUTH CELL PHONE:

Please enter a valid phone number.Format: (000) 000-0000.

YOUTH E-MAIL

example@example.com

YESNO

Brief Description

YESNO

Brief Description

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*

Please enter a valid phone number.Format: (000) 000-0000.

PARENT/GUARDIAN E-MAIL

example@example.com

3. PARENT'S CONSENT and YOUTH ASSENT

Enter participants name below*

is invited to participate in the Youth for Christ 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 learnskills,healthyrelationships,datingviolence,sexualdelayriskThisoflessonscouldto andsexualavoidanceconsists12and 8 take sessions program 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, which means 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 Youth for Christ. Nobody except the program manager and project analyst will have access to this form.

If you agree to let your youth participate, please read this statement and sign below.

My signature here means that give my consent to allow my child/ward to participate in the Youth for Christ SRAE Teen Intervention Project in order to learn healthy relationship skills:

Parent/Guardian Signature*

Date*

Date

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. 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 - authorize Youth for Christ 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

Date

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

YOUTH ASSENT

I understand what the Youth for Christ SREA Teen Intervention Project program is about and what to expect if I join in. I also understand my participation is voluntary and that the program staff will keep my participation condifential. I was given questions about the program. My signature below means that I agree to participate.

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

Date*

Date

PROJECT CONNECT209