Registration for 'If You Know, You Know'
Join us every Sunday in November at Southeast Public Library for engaging discussions on creating healthy relationships and preventing dating violence.
Important Information
Please be aware that some topics discussed during our sessions may touch on sensitive subjects. Emotional support will be available throughout. As a faith-based organization, we strive to provide a compassionate and supportive environment. Guardians are welcome to stay during the sessions, though drop-off is encouraged to allow participants to fully engage.
Participant Name
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First Name
Last Name
Age
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Please Select
13
14
15
16
17
18
19
20
21
Gender
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Male
Female
Non-binary
Prefer not to say
Zip Code
Guardian/Parent Name
*
Guardian Phone Number
*
Guardian Email (optional)
Household Type
*
Two biological parents (married)
One biological parent household
Split time between biological parents
Two-parent home (biological parent remarried)
Single parent
Foster or guardian care
Other
Please specify if Other for Household Type
Are you currently dating?
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Yes
No
If yes, what age did you start dating?
11 or younger
12–13
14–15
16–17
18+
Have you ever experienced dating violence?
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Yes
No
Prefer not to say
Have you ever witnessed or been exposed to dating violence?
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Yes
No
Not sure
Which sessions are you available to attend?
*
Sunday, November 2 – 3:15–5:45 PM My Truest Identity (Self Value& Worth)
Sunday, November 9 – 3:15–5:45 PM Recovering My Character (A testimony of surviving sexual assault)
Sunday, November 16 – 3:15–5:45 PM Date the right way (The Do's & Don't of dating)
Sunday, November 23 – 3:15–5:45 PM I can see clearly now (identifying the signs of dating violence)
Sunday, November 30 – 3:15–5:45 PM How far we've come and how far we will go. (Celebration of accomplishment)
Do you have any food allergies or dietary restrictions?
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None
Vegetarian
Vegan
Gluten-free
Nut allergy
Dairy allergy
Other
Emergency Contact Name
*
Emergency Contact Phone
*
Please specify if Other for Food Allergies or Dietary Restrictions
Relationship to Participant
Household Income Range
Under $25,000
$25,001–$50,000
$50,001–$75,000
$75,001–$100,000
$100,001+
Prefer not to say
What would you like the participant to learn or talk about during this event?
Building self-worth
Setting boundaries
Recognizing red flags
Healthy communication
Other
If you selected 'Other', please specify.
Parent/Guardian Consent
*
Participant Signature
*
Parent/Guardian Signature
*
Date
*
-
Month
-
Day
Year
Date
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