zzzApplication for Hope Rocks

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Email *

Parent/Guardian's Name *

Parent/Guardian's Best Contact Number *

Is it ok to text you? *

Yes

Teen's Name *

Name Your Teen Prefers to be Called

Teen's Age *

The fall session will start on Monday September 12 from 4 to 6 pm. Does your teen have transportation? (Depending on location I may be able to provide transportation to each session.) *

Yes

Other:

Do I have permission to send your teen messages in a group text? *

Yes

My teen does not have a phone.

If yes, what is your teen's phone number?

Does your teen have permission to join a private Facebook group for Hope Rocks? *

Yes

My teen does not have Facebook.

Do I have permission to use your child's photograph and words to promote Coastal Carolina Outreach? (I will only use first names and ask permission before quoting anyone.) *

Yes

What do you hope your teen gains from this program? *

Is there anything in particular you feel I should know about your teen? *

Please check each rule for Hope Rocks as you read it. The teens will read and sign off on the rules at the first session. *

Be respectful and patient with each other.

Maintain confidentiality. (EXCEPTION: if any abuse or harm is suspected.)

Be a good listener.

Participate in group discussion and activities.

Keep an open heart and an open mind.

Phones will not be used except during breaks or a specific activity.

A teen will be dismissed from the group at the leader's discretion based on the rules of the group.

Required

By typing my full name here, I am confirming that I am the legal guardian/parent of this teen, my responses are sincere, and I understand the rules for Hope Rocks. Hope Rocks is in no way designed to replace professional mental health services. The leader is a group life coach and educator with the goal of helping teens develop healthy coping strategies to handle stress and improve self-esteem. *Your spot in the program is not guaranteed until confirmed by Carrie Higgins, Executive Director of Coastal Carolina Outreach. *

Contact Information for Hope Rocks

Leader: Carrie Higgins

Phone Number: 910-617-7219

email: coastalcarolinaoutreach@gmail.com

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