Empowered Discussion Group Interest Form

Empowered Discussion Group Interest Form

Thanks for your interest in participating in our very first Empowered Discussion Group! This group of students will meet with our Empowered Team once in March and once in May to provide feedback about our Empowered program. Your valuable input will help us equip and empower more youth in our community with life-changing healthy relationship skills.
Student Information
Student Name*

First NameLast Name
Gender*

MaleFemale
Current Grade*
Birth Date*

MonthDayYear
Cell Phone Number*
Personal Email Address*
Not your school email.
Parent/Guardian Information
Name*

First NameLast Name
Relationship to Student*
I.e. mother, father, grandparent, etc.
Cell Number*
Email*
example@example.com
Meeting Locations & Time
At which location(s) would you be most interested in having our meetings (please select all that interest you):*

Top GolfCoffee shopObria Medical Clinics (tour included)Public ParkOther (select if you have a suggestion)
Meeting times that would work for you (please select all that apply):*

Monday Afternoon (4pm - 5:30pm)Monday Evening (6pm - 7:30pm)Tuesday Afternoon (4pm - 5:30pm)Tuesday Evening (6pm - 7:30pm)Wednesday Afternoon (4pm - 5:30pm)Wednesday Evening (6pm - 7:30pm)Thursday Afternoon (4pm - 5:30pm)Thursday Evening (6pm - 7:30pm)Friday Afternoon (4pm - 5:30pm)Friday Evening (6pm - 7:30pm)
Incentives for Participation

Your time is valuable to us! We want to give you a gift for participating in our Discussion Group. Please let us know what incentive would be meaningful to you.
Participation incentives (please select all that would be meaningful to you):*

Gift card to restaurant/storeMovie theatre gift cardMeeting location activity (i.e. we pay for you to play at Top Golf)Stanley Mug/BottleBluetooth speakerOther (select if you have a suggestion)
Should be Empty:

Empowered Discussion Group Interest Form

Student Information

Parent/Guardian Information

Meeting Locations & Time

Incentives for Participation