LiFT Registration Form

1

What is your preferred language?* This field is required.Please select

EnglishSpanish

2

Thank you for your interest in the Linking Families and Teens [LiFT] program!

Location: Crooked Oak High School- Oil Slick Room

Time: 9:00 am to 3:30 pm

Date: Saturday, September 13, 2025

LiFT is a family communication evidence-based program that helps families share their values, build family bonds, and talk about the tough stuff – including sexual health and supportive relationships. It is designed for youth between the ages of 13 and 19, as well as their parent(s) and guardian(s).

Breakfast, lunch, and snacks will be provided.

Caregiver sessions will be presented in Spanish.

Please complete these forms for you, your child/children, and any other adult who will be participating in the LiFT program with you!

3

Will you need financial assistance for childcare during the LiFT program?* This field is required.There will NOT be childcare services for children under the age of 13. A childcare stipend will be available for children under the age of 13. Youth participants must be at least 13 years of age to attend the event.

YESNO

4

Parent/Guardian's Name* This field is required.

First Name

Last Name

5

Parent/Guardian's Birth Date* This field is required.Please enter as MM-DD-YYYY or use the date picker option.

6

Parent/Guardian's Email(NOTE: Teen Clinic may contact you through email pertaining to the LiFT program)

example@example.com

7

Parent/Guardian's Phone Number* This field is required.(NOTE: Teen Clinic may contact you by phone pertaining to the LiFT program)

Please enter a valid phone number.

8

Parent/Guardian's Mobile Carrier* This field is required.

9

Parent/Guardian's Dietary RestrictionsBreakfast and lunch will be provided. Please let us know if you have any allergies or dietary restrictions.

10

Will another parent/guardian attend LiFT with you?* This field is required.

YESNO

11

Additional Parent/Guardian's Name

First Name

Last Name

12

Additional Parent/Guardian's Birth DatePlease enter as MM-DD-YYYY or use the date picker option.

13

Additional Parent/Guardian's Email(NOTE: Teen Clinic may contact you through email pertaining to the LiFT program)

example@example.com

14

Additional Parent/Guardian's Phone Number(NOTE: Teen Clinic may contact you by phone pertaining to the LiFT program)

Please enter a valid phone number.

15

Additional Parent/Guardian's Mobile Carrier

16

Additional Parent/Guardian's Dietary RestrictionsBreakfast and lunch will be provided. Please let us know if you have any allergies or dietary restrictions.

17

Child's Name* This field is required.

First Name

Last Name

18

Child's Birthdate* This field is required.Please enter as MM-DD-YYYY or use the date picker option.

Date

19

The LiFT program is offered to people ages 13 to 19. Please reach out to our hotline at 405-882-3598 (English) or 4054396558 (Spanish) if you have any questions.

• If you entered this section incorrectly, tap "Previous" and correct your entry.

• If your child is outside of our age range, there's no need to fill out the form. You may close this window.

20

Child's Dietary RestrictionsBreakfast and lunch will be provided. Please let us know if you have any allergies or dietary restrictions.

21

Will another child attend LiFT with you?* This field is required.

YESNO

22

Child's Name* This field is required.

First Name

Last Name

23

Child's Birthdate* This field is required.Please enter as MM-DD-YYYY or use the date picker option.

Date

24

The LiFT program is offered to people ages 13 to 19. Please reach out to our hotline at 405-882-3598 (English) or 4054396558 (Spanish) if you have any questions.

• If you entered this section incorrectly, tap "Previous" and correct your entry.

• If your child is outside of our age range, there's no need to fill out the form. You may close this window.

25

Child's Dietary RestrictionsBreakfast and lunch will be provided. Please let us know if you have any allergies or dietary restrictions.