ENGLISH - Elementary PARTICIPANT APPLICATION PC209

Year 1 Participant Application

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 Teen Intervention Project where he/she will learn relationship skills, that will help him/her with youth development in but not limited to life learn skills, healthy relationships, dating. This program consists of 12 lessons and could take 8 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. 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 Teen Intervention Project in order to learn healthy relationship skills:

Parent/Guardian Signature*

Date*

Date

YOUTH ASSENT

I understand what the 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 the opportunity to ask 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 CONNECT 209