ACCAP Youth Registration

ACCAP Student Registration Form

Agents of Change Community Ambassadorship Program
REGISTRATION CLOSES ON SEPTEMBER 12, 2025
Student Full Name*

First NameMiddle NameLast Name
Preferred Name (Nick Name)

First NameLast Name
Birth Date*

MonthDayYear
Gender*
Race/ Ethnicicty*
Grade*
School and School District*
How did you learn about this program?*

Contact Information
Parent/ Guardian Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/ Guardian Email Address*
Parent/ Guardian Cell Number*
Student Email
example@example.com
Student Cell Number

Emergency Contact
Emergency Contact Name (cannot be the parent listed above)*

First NameLast Name
Relationship to Student*
Emergency Contact Cell Number*
Emergency Contact Name (cannot be the parent listed above)

First NameLast Name
Relationship to Student
Emergency Contact Cell Number

Program Questionnaire

Please allow the student to complete this section.
1. Why do you want to be part of the ACCAP program?*
2. What does leadership mean to you?*
3. Tell us about a time you stood up for something you believed in. What happened?*
4. What is one issue in your school, neighborhood, or community that you care about, and why?*
5. What strengths or talents do you bring to a team?*
6. What would you like to improve or grow in during this 8-week program?*
7. Have you ever participated in a leadership or mentorship program before? If yes, tell us a little about it.*
8. What are your future goals or dreams?*
9. Are you comfortable speaking in front of others or working in groups?*
10. Is there anything else you want us to know about you?*

Permissions & Agreements
Liability Waiver

By signing below, I acknowledge that I am voluntarily allowing my child to participate in the Agents of Change Community Ambassadorship Program (ACCAP), hosted by Cornerstone Changemakers and held at St. Louis Community College–Florissant Valley, from September 20 to November 8, 2025.

I understand that participation in this program may include physical activity, group engagement, and on-site learning experiences that carry inherent risks. I hereby release and hold harmless Cornerstone Changemakers, St. Louis Community College–Florissant Valley, their employees, volunteers, board members, instructors, and affiliates from any and all liability, claims, demands, or causes of action arising from or related to my child’s participation in this program. This includes, but is not limited to, injury, illness, personal loss, or property damage.

I acknowledge that all reasonable safety precautions will be taken by the program organizers and understand that I will be notified promptly in case of an emergency.
Media Consent Waiver

I hereby give consent and permission to Cornerstone Changemakers to record the appearance, physical likeness and/or voice on videotape, on film, or digital video disk, or other means, and/or take photographs of the appearance of my child, who is listed as the student on this registration form. I hereby freely and voluntarily consent to the use and publication of my child's name, participation, picture, and/or likeness by Cornerstone Changemakers and/or its employees and/or agents, as well as the entity seeking this consent, and photographs, video and/or audio for any and all purposes including, but not limited to, educational, promotional, advertising, and trade, through any medium or format, including, but not limited to, film, photograph, television, radio, digital, internet, or exhibition, at any time from this date forward until I revoke this consent in writing. I acknowledge that Cornerstone Changemakers is the sole owner of all rights in, and to, this visual and/or sound production and/or photograph(s) and the recordings, thereof, and that it has the right to use or reproduce the resulting images and/or sound as often as it finds necessary. I acknowledge that the photographs, video and/or audio may be used indefinitely by television, radio, newspapers, magazines, newsletters, brochures, Internet, intranet, or in other media once released. Cornerstone Changemakers has the right, among other things, to edit and/or otherwise alter the visual or sound recording, or photographs, as needed. I understand I will receive no compensation for the appearance of the above-named person or for participation in said productions. I agree to hold the Cornerstone Changemakers, its employees and other parties harmless against claim, liability, loss, or damage caused by, or arising from, my participation in this production. I have read this Consent before signing below and fully understand the contents, meaning and impact of this consent. I understand that I am free to address any specific questions and have done so prior to signing this Consent.
Please check one.*

I consent.I am revoking this consent.
Please Check each box.*

ATTENDANCE AGREEMENT: I understand that ACCAP runs every Saturday from September 20 to November 8, 2025, from 8:00 AM to 12:00 PM at STLCC–Florissant Valley. I commit to attending each session regularly, arriving on time, participating fully, and honoring the time and effort of my peers and facilitators.BEHAVIOR AGREEMENT: I understand that my child is expected to participate respectfully, responsibly, and safely during the ACCAP program. I acknowledge that if my child engages in repeated disruptive or inappropriate behavior, they may be dismissed from the program. I agree to support ACCAP staff in upholding these expectations.COMMUNICATION AGREEMENT- I agree to check email, text messages, or the Band app regularly for updates from ACCAP staff. I understand that important reminders, announcements, and program details will be shared through these channels. I also give permission for my child to participate in ACCAP group chats for the purpose of receiving information, encouragement, and peer connection in a safe, monitored environment.
Parent Signature*

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ACCAP Student Registration Form

Contact Information

Emergency Contact

Additional Questions

Program Questionnaire

Permissions & Agreements