Person completing this form: YOUR relationship to the Participant *PARENTLEGAL GUARDAINFAMILY FRIENDSELF (I am 18 years or older am consenting myself)Participant Contact InformationParticipant Name *Gender *FemaleMaleDoesn’t IdentifyOtherRace/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/LatinoWhat is the Participant AGE *What GRADE is the Participant inStreet Address *Apartment, suite, etcCity *State/Province *ZIP / Postal Code *Email Address *Phone Number *Parent / Guardian Contact InformationNameEmail Address *Phone Number *Participants will:* 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 referrals, if needed to: a local Teen Clinic, Teen Therapy, and other needed services* Go on educational group tours* Be inducted as a Youth Community Change Commission (YC3) memberPlease 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 MemberOtherDoes the participant has any allergies? If so, please list:Send Registration
