2023 Youth Wellness Expo Registration Form
Nu Collar Solutions, LLC premiere program Kings Corner will be kicking off the spring session with the inaugural Youth Wellness Expo on Saturday, March 25, 2023, from 10:30 am to 3 pm at the Boys & Girls Clubs of Metro Richmond Teen & Community Center located at 1830 Creighton Road, Richmond, Virginia 23223. This event is open to all youth in the Richmond area ages 12-18 (young ladies & young men welcomed).  We will have sessions focusing on self-care, job interview skills, and a panel discussion on building healthy relationships.   
Sign in to Google to save your progress. Learn more
Email *
Student First Name *
Student Last Name *
Date of Birth *
MM
/
DD
/
YYYY
School Attending in Spring 2023 *
Grade Level Spring 2023 *
Student ID Number
Gender *
Ethnicity *
Has your child's school identified them as an English Language Learner (this means English is their second language)? *
Parent/Guardian #1 First and Last Name *
Relationship to Youth *
Preferred Language for Communication *
Home/Mobile Phone
Address *
Apt/Unit# *
City, State, Zip *
Parent/Guardian #2 First and Last Name
Relationship to Youth
Preferred Language for Communication
Home/Mobile Phone 
Email Address
Address
Apt/Unit#
City, State, Zip
Emergency Contact First and Last Name (Other than the person completing this form) *
Relationship to Youth *
Preferred Language for Communication *
Home/Mobile Phone *
We ask for this information to get a better understanding of the families we serve and to ensure that resources are equitably distributed across the City of Richmond. Your personal information will not be reported.

Household Income *
Total Number of Adults in Household (19 years of age or older) *
Total Number of Children in Household (18 and younger) *
Please list persons who are authorized to drop off and pick up your child.  Please include their full name, and the best phone number to be reached.  

*A valid form of identification will be required to be shown prior to picking any child up from our program i.e. driver's license, military ID  
 *
Medical Information

To provide a fun and safe program experience for your child, we would like to know if they are currently taking any medication(s) during program hours or have any allergies. Students will be responsible for taking their own medication.  We will provide them with a safe space and privacy to take their medication as needed. This information will not be shared except as necessary in the event of a medical emergency.
Medicine needed during program hours *
If yes, please list medicine and dosages here
Allergies *
If yes, please list allergies here
Does your child have any special needs that we should know about? 
Clear selection
If yes, please explain
Is there anything else that you like the program staff to know about your child?
Consent to Disclose Student Records for Record Sharing

This program, Kings Corner, is funded by the City of Richmond’s Positive Youth Development and Youth Violence Program. The goal of the City of Richmond’s Positive Youth Development and Youth Violence Program is to promote positive youth development and prevent youth violence and help a child reach their full potential—socially, emotionally, and academically. To help the City of Richmond achieve that goal, we may need to share certain information about your child with the City of Richmond and NextUp RVA. The City of Richmond has contracted NextUp RVA to distribute funds to programs, provide technical assistance to programs and evaluate programs’ impact on youth outcomes. In turn, they may need to share certain information about your child with us. NextUp RVA is committed to ensuring all youth have a positive, quality learning experience, and sharing this information can help us better serve your child(ren). Additionally, this information will help us understand whether or not this program is having a positive impact on your child’s academic, social, and emotional well-being.
Also, to improve the program and make sure it meets the needs of youth, schools, and the community, we may conduct surveys to ask questions about the kinds of programs students would like to see, what they are learning from their participation in the programs and how they view themselves as learners and how they relate to their peers and adult staff. The answers to the surveys will be used to evaluate and improve the City of Richmond’s Positive Youth Development and Youth Violence Program.
By signing below, you consent to have RPS release your child’s student record to a data management system operated by a third-party partner, Cityspan Technologies (cityspan.com), and NextUp RVA. The student record has information such as your child’s attendance, grades, scores on SOL, NWEA MAP, and Imagine Learning assessments, types of services they may receive, discipline history, and demographic information. Having this information helps us better understand how our services work and how we can improve them to help your child be more successful. 
*
Media Release
Sometimes, Kings Corner may use photos of participants in publicity and marketing materials, such as on the program’s website and social media. 
*
Parent/Legal Guardian’s First and Last Name (this will serve as your signature)
 *
Date *
MM
/
DD
/
YYYY
A copy of your responses will be emailed to the address you provided.
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy
Google Forms