Youth Leadership & Well-being Sign-up

Youth Leadership & Well-being Sign-up

Thank you for your interest! We're excited to connect with you. Please note that if you're a minor (i.e., under the age of 18), a parent/guardian signature is required to submit this form.
Are you a current member of our Leadership & Well-being Community or the Butterfly Dreamz Cocoon Club?*

Yes, I signed up previously!Nope, this is my first time signing up.
Did one of our interns invite you to join our Leadership & Well-being community or our Cocoon Club? If so, please select their name. *
Your Name*

First NameLast Name
Your Email*
example@example.com
Your Phone Number*
Please enter a valid phone number.
Do you respond to text messages at this number?*

YesNo
Butterfly Dreamz, Inc. and The Black Man Can, Inc. are excited to partner this year! To help us better support you, please let us know which organization is most aligned with your identity.*

Butterfly Dreamz, Inc.The Black Man Can, Inc.
Where do you live?*

Newark, New JerseyGary, IndianaOther
Are you a current student at one of our partner schools? If so, please select the school that you attend.*

Cleveland Elementary School (Newark, NJ)West Side Leadership Academy (Gary, IN)No, I don't attend any of the schools listed.
Which best describes you?*

Middle School StudentHigh School Studentc/o 2023 High School Graduatec/o 2022 High School Graduatec/o 2021 High School Graduatec/o 2020 High School Graduatec/o 2019 High School GraduateOther
What grade are you in?*

7th grade8th grade9th grade10th grade11th grade12th gradeOther
What's the name of your school?*
Where is your school located?*

Newark, New JerseyGary, IndianaOther
Are you currently enrolled in a college/university or another post-secondary education/career program (e.g., trade school, gap year program, etc.)?*

YesNo
What's the name of your college, university, or career/education program?*
Where is your college, university, or career/education program located?*

Newark, New JerseyGary, IndianaOther
When is your expected graduation month and year (e.g., May 2024)?*
Which leadership and activities interest you most? Check all that apply.*

Leadership & Wellness Coaching - Meet with a Community Wellness Coach, who will provide you with mentorship and support to help you achieve your personal, academic, and future career goals.College Chats - connecting with diverse college students about their experiences.Career Chats - meeting professionals and exploring different careers and industries.Wellness Weekend - a 3-day mentorship weekend where teens and young adults get connected to the support they need to build healthy and fulfilling lives.Saturday Outings & Field Trips - all-expense-paid exploration trips that will broaden your understanding of diverse cultures, arts, and career paths.Community Care Packages - volunteer your time by helping our team create care packages for our community members, including our recent high school graduates.Cocoon Club - a supportive online community that connects women and girls to leadership opportunities, college and career resources, and mentorship.
Agree or Disagree: I feel supported by my school counselor or college advisor and comfortable reaching out to them for help.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly DisagreeN/A, I don't have a school counselor or college advisor.
Would you like to RSVP for our Tuesday meetings at West Side Leadership Academy in Gary, Indiana?

Yes, sign me up!No, thank you.
Would you like to RSVP for our next Saturday session at the Community Save Zone, located at 500 Springfield Ave, Newark, NJ 07103? Butterfly Dreamz facilitates programs every 4th Saturday of the month!

Yes, sign me up!No, thank you.
Would you like to apply to receive a $100 Cocoon Club Cash award for a recent leadership achievement?*

Yes, I recently achieved something I'm proud of, and I'd like to share it!No, not right now.
Please tell us more about you and your leadership achievement by answering ALL of the following questions: 1.) What is your definition of leadership? 2.) What did you recently achieve, and how does it reflect your definition of leadership? 3.) How does this achievement help you and/or others in your community? *
Our team is working on a research project to help us better understand the well-being of youth (ages 12 to 24) in our community. Would you like to enter a raffle for a $50 gift card by answering additional survey questions for our research project now?*

Yes, let's go!No, thank you.I've already completed the survey.
Which THREE (3) well-being areas are most important to you right now?*

My education (getting a high quality education and growing intellectually)My physical health (making sure I'm physically healthy)My emotional and mental health (getting support for my emotional and mental health)Our environment (protecting and taking care of the planet, my community, or my personal spaces)Social and political issues (getting involved in social and political issues)My spiritual development (growing my faith and spirituality practices)My future or current career (finding meaningful and well-paying work)My finances (building and maintaining financial wealth)I'm not sure
AGREE or DISAGREE: School causes me to feel very stressed and/or anxious, and it has impacted my daily routine.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: I am aware of my family's medical history and know what preventative measures I can take to care for myself.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: There is a stigma on emotional and mental health issues within my COMMUNITY.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: There is a stigma on emotional and mental health issues within my FAMILY.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: I know how to get the right support for my emotional and mental health needs?*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: I know who the important local public officials are in my city/town (e.g., mayor, council members, school board members, etc.), what their roles are, and how to contact them.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: I have many opportunities to learn about and explore various career paths that fit my interests and passions.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: I receive regular guidance on how to practice healthy financial behaviors and build financial wealth.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: My NEIGHBORHOOD has healthy food options.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: My HOME has healthy food options.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: I have regular access to clean tap water.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
AGREE or DISAGREE: My neighborhood is safe.*

Strongly AgreeAgreeNeither Agree nor DisagreeDisagreeStrongly Disagree
Would you be interested in receiving a $25 gift card to participate in a community listening session, where you'd share your thoughts and opinions about the well-being of youth in our community?*

Yes, please keep me posted!No, thank you.
Thank you for completing our survey questions! Every month, we randomly select a new $50 raffle winner. If you win the raffle, you'll receive your gift card to the email address you provided in this form.*

Ok! I understand that if I win the raffle my gift card will be emailed to me at the email address I provided.
To learn more about how we can increase diversity in our community, we invite you to voluntarily provide the following demographic information at the end of this form.
Gender*

FemaleMaleNon-binaryDecline to Self-IdentifyOther
Race/Ethnicity*

AsianBlack or African AmericanHispanic or LatinxNative American or American IndianNative Hawaiian or Other Pacific IslanderWhiteDecline to Self-IdentifyOther
How old are you?*
When is your birthday?*

MonthDayYear
Date
Parent or Guardian's Name*

First NameLast Name
Parent or Guardian's Email*
example@example.com
Parent or Guardian's Phone Number*
Please enter a valid phone number.
Parent or Guardian's Signature*

Clear
Please verify that you are human*
Should be Empty: