R3P Youth Resilience & Leadership Development Application

Youth Resilience & Leadership Development Application

Apply to join the R3P cohort for youth ages 12–17. Complete all sections to help us understand your goals, ensure safety, and confirm participation consent.
Participant Information

Tell us about the youth applying to the R3P program.
Participant Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Age (Eligible: 12–17)*
School Name*
Current Grade Level*
Home Address*

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Parent/Guardian Information

Contact information for the parent or legal guardian.
Parent/Guardian Full Name*

First NameLast Name
Relationship to Participant*
Primary Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Parent/Guardian Email Address*
example@example.com
Emergency Contact Name (if different from parent/guardian)
Emergency Contact Phone (if different from parent/guardian)
Please enter a valid phone number.Format: (000) 000-0000.
Participant Background & Goals

Help us understand your interests and goals for joining R3P.
Why are you interested in joining R3P?
Emotional RegulationConfidenceLeadership SkillsCommunicationStress ManagementAccountability & HabitsPhysical ReadinessDecision-Making
YesNo
If yes, please describe your previous program participation.
What goals would you like to accomplish during this cohort?
Commitment & Expectations

Review and acknowledge program expectations.
I acknowledge and commit to program expectations.
Participant Signature - Expectations*

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Date - Expectations Signature*

MonthDayYear
Date
Parent/Guardian Agreement

Parent/guardian must review and agree to participant's involvement.
I acknowledge and support my child’s participation.
Parent/Guardian Signature - Agreement*

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Date - Parent/Guardian Agreement*

MonthDayYear
Date
Referral Source & Additional Information

How did you hear about R3P and anything else you'd like us to know?
SchoolCommunity OrganizationSocial MediaReferralWebsiteOther
Any additional information you would like us to know?
Medical Information & Liability Acknowledgment

Disclose any medical conditions or treatment that may impact participation.
NoYes
If yes, please describe the medical condition(s).
NoYes
If yes, please explain the treatment or limitations.
Parent/Guardian Signature - Medical Disclosure & Liability Waiver*

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Date - Medical Disclosure & Waiver*

MonthDayYear
Date
Code of Conduct Agreement

Agreement to uphold R3P's standards of conduct.
Participant Signature - Code of Conduct*

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Date - Code of Conduct Participant*

MonthDayYear
Date
Parent/Guardian Signature - Code of Conduct*

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Date - Code of Conduct Parent/Guardian*

MonthDayYear
Date
I grant permission for my child to be photographed or recorded for official R3P use.I do NOT grant permission.
Parent/Guardian Signature - Media Release*

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Date - Media Release*

MonthDayYear
Date
Should be Empty:

Youth Resilience & Leadership Development Application

Participant Information

Parent/Guardian Information

Participant Background & Goals

Commitment & Expectations

Parent/Guardian Agreement

Referral Source & Additional Information

Medical Information & Liability Acknowledgment

Code of Conduct Agreement