Mental Health Clinic Registration
Register by September 4th for the FREE event below!! The Sixth Avenue CDC is excited to bring middle and high school students to a Mental Health Clinic sponsored by Councilor Crystal Smitherman, in partnership with the Black Women’s Mental Health Institute, on September 12, 2026. Event is from 9:00am - 1:00pm *Transportation will be provided, but seating is limited. Departure time is 8:30 am from the church foyer.
Student Full Name
*
First Name
Last Name
Student Email Address
*
example@example.com
Student cell number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Grade
*
Please Select
6th
7th
8th
9th
10th
11th
12th
School Name
*
Student allergies
Gender
*
Male
Female
Non-binary
Prefer not to say
Other
Student Agreement- I agree to follow participation guidelines that will be reviewed a the virtual parent/student meeting
*
Yes
No
Transportaion Agreement
*
Self-driving
Parent /Guardian will be providing transportation
Bus transportation provided (departure at 8:30 am)
I give permission for my child/children to be transported by Sixth Avenue CDC and travel by church bus/van/, therefore releasing liability to Sixth Avenue Baptist Church and Sixth Avenue CDC ( "NA" if they are not riding the bus/van).
*
Yes
No
NA
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email Address
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
I give permission for my child to participate in the Mental Health clinic with Sixth Avenue CDC on 9.12.2026.
*
Yes
No
Chaperone volunteer
Chaperone name
Chaperone email
example@example.com
Chaperone cell number
Please enter a valid phone number.
Format: (000) 000-0000.
I will meet at the church between 8:15-8:30 am for departure at 8:30. I will depart at 8:30 am along with the group and trail the bus to the Crossplex. I agree to supervise participants and help keep them engaged and assist with loading and unloading.
*
Yes
No
Register
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