Please complete the information below: Person completing this form: YOUR relationship to the Participant * PARENTLEGAL GUARDAINFAMILY FRIENDSELF (I am 18 years or older am consenting myself) Participant Contact Information Participant Name * Gender *Female Male Doesn’t Identify Other Race/Ethnicity *Please select an optionWhite, non-Hispanic/LatinoBlack, non-Hispanic/LatinoAsian, non-Hispanic/LatinoAmerican Indian/Alaska Native, non-Hispanic/LatinoNative Hawaiian/Other Pacific Islander, Non-Hispanic/LatinoMore than one race/ non-Hispanic/LatinoRace unknown/not reported, non-Hispanic/LatinoWhite, Hispanic/Latino What is the Participant AGE * What GRADE is the Participant in Street Address * Apartment, suite, etc City * State/Province * ZIP / Postal Code * Email Address * Phone Number * Parent / Guardian Contact Information Name Email Address * Phone Number * Participants will: * Be inducted as a Youth Community Change Commission (YC3) member * Become eligible to receive a scholarship (High School Seniors Only) * Participate in training on Healthy Relationships via Love Notes SRA curriculum and Youth Participatory Action Research (YPAR) * Receive one-on-one mentoring * Participate in a Digital Photo & Video Project * Receive participation incentives * Receive referrals, if needed to: a local Teen Clinic, Teen Therapy, and other needed services * Go on educational group tours Please selectHow did you hear about us?RCBOEJuvenile CourtThankful Baptist Church/Talk ConsultingBeauty in the BrokenGeorgia Division of Family & Children ServicesJessye Norman School of ArtsHeritage AcademyMedical Assoicates PlusSerenity Behavioral Health SystemsAmerigroupGeorgia Department of Public HealthCSRA Regional CommissionBoys & Girls Clubs of the CSRAAugusta Housing AuthorityHope for AugustaGrantWest EnterprisesDept. of Juvenile JusticeCSRA EOAFriendFamily Member Other Does the participant has any allergies? If so, please list: Send Registration
