23-24 Teen Workshop - Registration

Teen Empowerment Workshop Event - First Thursday, Every Other Month, 5:45 pm to 7:45 pm

*Deadline to Register is Tuesday before the event @ 4 pm. You must hit SUBMIT Button for this form to go through*
Teen Empowerment Workshops: Building Resilience for Life's Journey

🌟 Join Us for an Inspiring Journey! 🌟

At Jacob's Mission Community Center, we're excited to offer our empowering series of Teen Workshops, specially crafted to equip teens with essential life skills and insights that will guide them toward a brighter future.

🗓️ Date: These dynamic workshops will take place every other month, providing opportunities for growth and learning throughout the year.

⏰ Time:

5:45 pm: Check-in
6:00 pm: Dinner
6:45 pm: Speaker
7:45 pm: Ice cream bar

📍 Location: Jacob's Mission Community Center

🏠 Address: 7830 E. University Dr. Mesa, AZ 85207

✨ Who can attend: This event is FREE for residents of Arizona who receive Temporary Assistance for Needy Families (TANF) benefits, low-income Arizona residents, or individuals with chronic illnesses or physical disabilities. We serve at-risk youth aged 13-19.

🧠 Workshop Topics: 1️⃣ Balancing Life: Learn to navigate the challenges of school, social life, and self-care effectively. 2️⃣ Mental Health: Discover strategies to support and maintain your emotional well-being. 3️⃣ Peer Pressure: Equip yourself with the tools to make confident, informed decisions. 4️⃣ Turning Setbacks into Set Ups: Transform challenges into stepping stones for success. 5️⃣ Mindset Matters: Cultivate a positive outlook that fuels personal growth and resilience. 6️⃣ Success Starts with Discipline: Master the art of setting goals and achieving them.

Our workshops are designed to be engaging, interactive, and led by experts who understand the unique challenges that today's teens face.

Join us at Jacob's Mission Community Center for an incredible journey of self-discovery, skill-building, and connection with peers who share your aspirations.

🚨 Registration Deadline: Tuesday before the event @ 4 pm

For questions, call (623) 428-1592 or email Volunteer@ASANow.org

⚠️Cancellations: Space is limited, so please only sign up if you are committed to attending. You must notify us 24 hours before the event; otherwise, your registration for the next 60 days will be revoked. Thank you for your understanding. We want to continue offering these free workshops to the community and rely on your communication and participation to continue."

Feedback: Our donors and volunteers love feedback. If JMCC has blessed your life, please take a minute to leave a positive review on Google and/or on our ASA Now Facebook Page or email us at Hope@asanow.org with your testimonial.

With Gratitude,

Angela Teachout

Susan Woodruff

Anika Robinson

"Never doubt that a small group of thoughtful, committed citizens can change the world; indeed, it's the only thing that ever has". Margaret Mead

Search our events tab on Facebook for future events

www.asanow.org

*Be sure to CONSENT, SIGN & hit the SUBMIT button*
Workshop Date

November 2nd 2023
We need to capture some important information to help coordinate the event.

Please take a moment to fill out this form in its entirety.

If a foster child leaves your home or a new one is placed, please let us know as soon as possible.

*Be sure to CONSENT, SIGN & hit the SUBMIT button along with your payment. An automatic confirmation email will be received*
If you are a Foster or Kinship family, would you like to be considered to receive Free Food and Clothing from ASA Now?*

YesNo
Are you an (check all that apply)*

Unlicensed Kinship CaregiverGroup HomeLicensed Foster/kinship CaregiverTribal Foster CaregiverFoster/ Adoptive FamilyNone of the Above
Name of Group Home if applies
Primary Caregiver's Name #1*
Primary Caregiver's Name #2
Current Address*

Street Address

CityState

Zip Code
Cell Phone Number*

Area CodePhone Number
Emergency Cell Phone Number*

Area CodePhone Number
E-mail*
Total Number of People Currently Living in the Home?*
Includes all Adults and Children
Number of Adults Living in the Home?*
(This includes adult children age 18 and over who are out of high school)
Total Number of Children Living in the Home?*
(Children under 18 and those over 18 who are still in high school)
Number of Foster, Tribal Foster, or DCS Guardianship Children Living in the Home?*
(This does NOT include non-DCS kinship or guardianship without DCS involvement.)
Number of Adopted Children Living in the Home?*
(Under 18 and those over 18 who are still in high school)
Number of Biological Children Living in the Home?*
(Under 18 and those over 18 who are still in high school)
Number of Non-DCS Kinship or Guardianship Children WITHOUT DCS Involvement Living in the Home?*
(Under 18 and those over 18 who are still in high school)
We are required to gather data about the children, youth, and families we serve. The next question will ask if your family falls below the following income levels based on household size: *1 person: $20,385 *2 people: $27,465 *3 people: $34,545 *4 people: $41,625 *5 people: $48,705 *6 people: $55,785 *7 people: $62,865 *8 people: $69,945 *Please add $4,270 for each additional household member. (IF YOU ARE A GROUP HOME, PLEASE SELECT YES.)*

YESNO
How many children will be in attendance ?*
How many of the total number of children in attendance are foster/tribal/DCS guardianship children?*
If you have a FOSTER, TRIBAL FOSTER, DCS GUARDIANSHIP CHILD or are a GROUP HOME please click YES and enter their information first, otherwise click NO.

YesNo

Foster, Tribal Foster, or DCS Guardianship Child's Information #10
10. Full Name:*

First NameLast Name
AGE*
Gender:*

MaleFemale
Ethnicity:*

WhiteHispanic or LatinoBlackAsian Pacific IslanderAmerican Indian/Alaskan WhiteMulti Ethnic
Please upload a copy of the foster child's NTP or DCS Guardianship paperwork.*
In case there is an emergency, we need to contact their DCS Case Specialist

Click Here to register additional children OR complete registration
Continue with Sign-up

Yes, register more children ( Biological, Adopted, non DCS)No more children to register, go to consent and submit form

Please sign up Children from youngest to oldest
Please be sure to sign up foster, tribal, and DCS guardianship children in the previous sections, NOT in this section
Child Number 1*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 2
Child 2 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 3
Child 3 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 4
Child 4 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 5
Child 5 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 6
Child 6 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 7
Child 7 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 8
Child 8 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 9
Child 9 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 10
Child 10 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 11
Child 11 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 12
Child 12 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 13
Child 13 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 14
Child 14 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Would you like to add another child?

YesNo

Child Number 15
Child 15 in Attendance*

First NameLast Name
Age*
Adopted/Biological/Other*

AdoptedBiologicalOther (this includes non-DCS kinship, and guardianship WITHOUT DCS involvement)
Continue with Consent

Yes

Click Here to Consent
Liability Release - I do hereby release ASA Now, Jacobs Mission Community Center, their agents, employees, personal representatives, affiliates, and any and all persons, firms or corporations liable or who might be claimed to be liable, whether or not herein named, from any and all claims, demands, damages, actions, causes of action or suits of any kind or nature whatsoever, arising out of or in any way relating to injuries and damages, as a result of being present on Jacobs Mission Community Center. I recognize that there may be inherent risks associated with attending or participating in this event. You have been fully informed of your consent, waiver of liability, and release before entering the event.
I have reviewed, understand, and agree to comply with the above terms*

Agree
By attending or participating in this event, you consent to interview(s), photography, audio recording, video recording and its/their release, publication, exhibition, or reproduction to be used for news, web casts, promotional purposes, telecasts, advertising, inclusion on websites, social media, or any other purpose by ASA Now and Jacobs Mission Community Center. Images, photos, and/or videos may be used to promote similar ASA Now events in the future, highlight the event and exhibit the capabilities of ASA Now. You release ASA Now, its officers and employees , and all persons involved from any liability connected with the taking, recording, digitalizing, or publication and use of interviews, photographs, computer images, video and/or sound recordings. By entering the event premises, you waive all rights you may have to any claims for payment or royalties in connection with any use, exhibition, streaming, web casting, televising, or other publication of these materials, regardless of the purpose or sponsoring of such use, exhibiting, broadcasting, web casting, or other publication irrespective of whether a fee for admission or sponsorship is charged. You also waive any right to inspect or approve any photo, video, or audio recording taken by ASA Now, Jacobs Mission Community Center or the person or entity designated to do so by ASA Now. You have been fully informed of your consent, waiver of liability, and release before entering the event.
I have reviewed, understand, and agree to comply with the above terms*

Agree
Signature*

Clear
Should be Empty:

Teen Empowerment Workshop Event - First Thursday, Every Other Month, 5:45 pm to 7:45 pm