SHOP Young Adult Registration Form

SHOP Young Adult Registration Form
Thank you for your interest in the SHOP program. Young adults ages 18-25 in Sacramento, Placer, and Yolo County who have experienced violence, witnessed violence, or have a close family member who has experienced violence, are eligible to register.

This form is confidential and will only be shared with SHOP staff, unless disclosure is required by law or authorized by you.

For any questions please call or text (916) 238-1713 or email SHOP@healthedcouncil.org.
Legal Name

First NameLast Name
Preferred Name
Enter the name you prefer to be called if different than your legal name. You will always be referred to with your preferred name in all contact from us.
How should we refer to you?

Other
Phone Number
Format: (000) 000-0000.
Email Address
example@example.com
Date of Birth

MonthDayYear
Gender

Other
How do you describe your race/ethnicity? (check all that apply)

Other
What county do you live in?
What is your zip code?
Enter the zip code you live in
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which SHOP site/ location are you applying to?
What type of health insurance coverage do you currently have?
If you are on Medi-Cal, please select the Managed Care Plan
Please list any food allergies
Specify any dietary restrictions that you have (I only eat halal food, I do not eat pork, dairy free, gluten free, etc. )
Is there anything you would like us to know that would help us support your participation? (for example accessibility needs, accommodations, health considerations, etc.)
This information helps us create a safe and inclusive environment and will be kept confidential.
Emergency Contact

First NameLast Name
Relationship
Emergency Contact Relationship to Participant
Emergency Contact Phone Number
Format: (000) 000-0000.
Life Experience

In order to provide the best support possible, it is helpful for us to understand the experiences you've have had. This information is only shared with SHOP staff working directly with SHOP participants.
The SHOP Program is funded by the California Office of Emergency Services (CalOES) to provide additional support to individuals who have witnessed, experienced, or been impacted by violence or harmful experiences.

This includes mass violence, hate crime, driving under the influence, kidnapping, bullying (verbal, cyber, or physical), sexual assault, child abuse, homicide, human trafficking, robbery, stalking/ harassment, domestic or family violence, and other forms of violence.

Individuals who have been impacted by one or more of these life events may be eligible for Emergency Financial Assistance or Victim’s Crime Compensation.
Have you been affected by one or more forms of violence or harm listed above?
Due to funding limitations, the SHOP program can only support individuals who have experienced, witnessed, or have a close family member who has experienced a crime such as the above examples.

If this does not apply to you, you may not be eligible for this program. Reach out to SHOP@healthedcouncil.org if you have questions or would like to verify your eligibility.
Have you experienced situations that may have impacted your safety, well-being, or sense of security?
Are there any areas where additional support or resources would be helpful for you at this time? (Examples: food, housing, transportation, mental health support, school support, etc.)
Consent and Liability Waiver
Participation Consent

I consent to participate in the SHOP program organized by Health Education Council. I understand that participation in this program may include group discussions, workshops, interactive activities, social events, community outings, field trips, recreational activities, and other program-related activities facilitated or supervised by Health Education Council staff or volunteers.
Assumption of Risk

I understand that participation in program activities may involve certiain inherent risks, including but not limited to accidental injury, illness, property loss, or other unforeseen events. I voluntarily choose to participate in program activities and assume responsibility for the risks resonably associated with participation.
Release of Liability

To the fullest extent permitted by law, I release and hold harmless Health Education Council, its directors, employees, volunteers, and agents from claims arising out of ordinary negligence related to my participation in program activities except where prohibited by law.
Emergency Medical Authorization

In the event of a medical emergency, I authorize Health Education Council staff or volunteers to seek emergency medical treatment on my behalf if I am unable to do so myself. I understand that reasonble efforts will be made to contact my designated emergency contact as soon as possible.
Code of Conduct Acknowledgement

I agree to treat other participants, staff, volunteers, and community members with respect and follow program rules and expectations.
Photo and Media Consent

Health Education Council may take photographs, videos, or audio recordings during program activities for use in promotional, educational, and outreach materials, incuding social media, websites, reports, and other publications.
Please select one:
Legal Name

First NameLast Name
Signature (Legal Name)
Today's Date

MonthDayYear
Should be Empty:

SHOP Young Adult Registration Form

Life Experience

Consent and Liability Waiver

Participation Consent

Assumption of Risk

Release of Liability

Emergency Medical Authorization

Code of Conduct Acknowledgement

Photo and Media Consent