Sisterhood of Storytellers Registration Form

1

Your Full Name* This field is required.

First Name

Last Name

2

Your Role and Title

3

Phone Number* This field is required.

4

E-mail* This field is required.

example@example.com

5

Relationship to Youth Being Referred* This field is required.

CASA

School Staff

Social Worker

Other

6

Youth's Name* This field is required.

First Name

Last Name

7

Youth's Age

12

13

14

8

Youth's Race/Ethnicity* This field is required.

10

Is the youth currently in therapy or receiving support services?* This field is required.

YESNO

11

Phone Number* This field is required.

12

Why do you believe this youth would benefit from the Sisterhood of Storytellers?* This field is required.

13

Does she have access to a device and internet to participate virtually?

YESNO

15

Is there anything else we should know to support her participation?* This field is required.(allergies, sensitivities, strengths, support needs, etc.)

16

This is a 3-month virtual journey that calls for heart, creativity, and consistency. Is she ready to show up for herself, grow her voice, and commit to turning her dreams into powerful stories the world needs to hear?* This field is required.

YESNO

17

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

18

Signature

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19

Date