CALL DR. JETER™ PROGRAM Enrollment Package

CALL DR. JETER™ PROGRAM Enrollment Package

Thank you for your interest in the Call Dr. Jeter™ Program. This enrollment package contains all required information, forms, and agreements for participation.
Participant Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
School/Organization
Phone Number*
Email*
example@example.com
Emergency Contact Name*

First NameLast Name
Emergency Contact Email *
example@example.com
Emergency Contact Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Participant Residential Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
CALL DR. JETER™ PROGRAM

CODE OF CONDUCT

This Code of Conduct outlines the expectations for all participants and facilitators in the Call Dr. Jeter™ program to ensure a safe, respectful, and supportive environment

Respect & Dignity
All participants must treat others with respect. Disrespectful language, harassment, or bullying will not be tolerated.
Confidentiality
Personal stories shared in the program must remain confidential. Facilitators are mandatory reporters if there is risk of harm.
Participation & Engagement
Participants are expected to arrive on time and engage respectfully. Silence is respected.
Emotional Safety
Participants are responsible for their emotional well-being. This program is not therapy.
Prohibited Behavior
Violence, threats, harassment, substance use, or disruptive behavior are prohibited.
Facilitator Authority
Facilitators may redirect or remove participants to maintain safety.
Consequences
Violations may result in warnings or dismissal from the program.
Acknowledgment & Agreement of Code of Conduct:*
Parent/Guardian Name*
Signature*
Date*

MonthDayYear
Date
Should be Empty: