DRE'S Safe Place Youth Leadership & Mental Wellness Program Application
Application for the Youth Leadership & Mental Wellness Program. Please complete the youth section and the parent/legal guardian or adult support sections as applicable. Program timing: applications open now through Sunday, October 4, 2026; youth conversations October 5-9, 2026; decisions by Monday, October 12, 2026; program meets Wednesdays from 4:00-6:00 PM starting October 28 for 16 weeks.
Youth Applicant Information
Youth's full legal name
*
First Name
Middle Name
Last Name
What name do you want us to call you?
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Age on October 28, 2026
*
Please Select
10
11
12
13
14
15
16
17
18
Other
Current grade
*
Please Select
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Other
School, homeschool program or community program
*
City
*
ZIP code
*
Youth phone number
Please enter a valid phone number.
Format: (000) 000-0000.
Youth email address
example@example.com
Adult Support Contact
Adult Support Person Full Name
*
First Name
Middle Name
Last Name
Relationship to Youth
*
Please Select
Parent
Guardian
Relative
Family Friend
Mentor
Teacher/School Staff
Coach
Other
Adult Support Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Adult Support Email Address
*
example@example.com
Eligibility, Interest, and Logistics
How did you hear about this program?
*
School counselor
Teacher or school staff
Friend or peer
Community organization
Social media
Flyer or poster
Family member
Other
Will you be between ages 14 and 18 when the program begins?
*
Yes
No
Can you attend Wednesdays from 4:00 to 6:00 PM beginning October 28?
*
Yes
No
Unsure
Can you commit to attending at least 14 of the 16 sessions?
*
Yes
No
Unsure
Are you choosing to apply because you are interested in the program?
*
Yes
No
Unsure
Is transportation likely to make weekly attendance difficult?
*
Yes
No
Maybe
Tell us what transportation support or planning may be needed.
Youth Short-Answer Prompts
Which parts of the program sound most interesting to you? Choose up to four.
*
Leadership activities
Mental wellness and self-care
Team projects
Public speaking or sharing ideas
Helping other youth
Creative activities
Community service
Other
Why do you want to be part of this program?
*
You do not have to be a leader already. What is one thing you want to become more confident doing?
*
When you feel stressed, angry, or overwhelmed, what do you usually do?
*
What does respect look like when young people are working in a group?
*
What is something adults often misunderstand about teenagers?
*
If you could change one thing for teens in your school or community, what would it be?
*
Which description sounds most like you in a new group?
*
I like to jump in and talk right away
I like to listen first and speak when I am ready
I like to work behind the scenes
It depends on the group or situation
Other
What helps you keep participating when an activity is not your favorite?
*
Is there anything that may make it hard for you to attend, participate, or feel comfortable in the program?
Youth Agreement and Signature
Youth commitment statements
*
I agree to participate respectfully
I will communicate honestly
I understand I can ask for help
I will follow program guidelines
Youth typed signature
*
Youth signature date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent or Legal Guardian Review
Are you the youth's parent or legal guardian?
*
Yes
Parent or legal guardian's full name
First Name
Middle Name
Last Name
Parent or legal guardian's phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or legal guardian's email
example@example.com
Did the youth know about the program and choose to complete their section?
*
Yes
No
Not sure
Can your household support on-time attendance and transportation each Wednesday?
*
Yes
No
Need to discuss
Other
List any known dates or recurring conflicts that could affect attendance
What do you hope the youth gains from this experience?
*
Is there anything practical DRE'S should know to help the youth participate successfully?
Adult Support Agreement and Signature
Adult support commitment statements
*
I agree to support the youth participant’s involvement in this program
I will encourage attendance and participation
I will communicate respectfully with program staff
Other
Adult typed signature
*
Adult signature date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
SUBMIT APPLICATION
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