Youth Interest Form 
About Rise Above:
Rise Above Youth Empowerment Program  is a mentorship program for middle to high school youth. The program includes events that will aim to raise awareness, increase prevention education, provide youth a safe space to learn, be active in their community, and advocate for themselves. Rise Above is funded by The Center at Sierra Health Foundation through the Elevate Youth California Grant. This grant aims to increase youth activism, mentoring, and peer support in order to prevent youth substance use disorder.

Expectations of the Program:
Participants will attend training one to two times a month on various topics related to youth issues, leadership, and prevention education. There will be one to two events a month for all participants in the program that include discussion panels, game nights, activities like escape rooms, pumpkin patches, and more. The expected timeline for children in the program is September-May.
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Email *
Youth First and Last Name *
Youth Preferred Name/Nickname
Date of Birth
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DD
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YYYY
Grade Level
Race/Ethnicity 
Gender (How Youth Identifies) 
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Do you identify as LGBTQ+? 
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Parent First and Last Name *
Address (for mailing purposes)  *
Phone Number (for youth and parent)  *
Email Address (for youth and parent)  *
Acknowledgement of Referral Form and Application 
By submitting this form, I give permission for my child to participate in the Rise Above Youth Empowerment community based mentoring program; For the volunteer matched with my child, who has been screened and approved by Rise Above; To have my child participate in an in-take interview conducted by Rise Above staff; To have my child talk with a Rise Above staff person about personal safety; and For Rise Above staff to provide contact information for me and my child to the volunteer. I understand that the program is not obligated to match my child with a volunteer and that as part of the enrollment process I will be asked to provide information through an in-person interview. I understand that the information I provide during the enrollment process will be kept confidential, unless disclosure is required by law and with exceptions noted. I understand that incidents of child abuse or neglect, past or present, must be reported to proper authorities. I understand that certain relevant information about my child will be discussed with the volunteer who is a prospective match (for example, demographic information, information relevant to volunteer preferences and information relevant to child-safety and well-being). I certify that all of the information on this form is true and correct to the best of my knowledge and that all income is reported. I understand this information is being given for the receipt of federal funds, that the information on this application may be verified and that deliberate misrepresentation of the information may subject me to prosecution under applicable state and federal laws. I understand this information will not affect my child’s qualification for this program. I do hereby release the organization and its employees, agents, members, volunteers and all other persons on its behalf from any and all liability for any damage or injury which such child might sustain while participating in said program and activities, including but not limited to any liability to any right of action that may occur to such child directly or to me as his/her parent/guardian. I understand that this information may be shared with my child’s school or with partnership agencies when applicable. If my child is matched, I agree to support my child’s match by reviewing the program and safety information given to me and immediately reporting any concerns I might have to Rise Above staff. 

I acknowledge the above information *
Media Release: Upon occasion photos or videos of participating children are used for brochures, posters, social media or miscellaneous promotions for the Rise Above Youth Empowerment Program. I hereby consent to and authorize the use and reproduction by Rise Above, or any authorized agent, of any photographs, video, or audio recording which Rise Above has taken of my child without further compensation to me. All photos and videos are the property of Rise Above and Kings Partnership for Prevention (KPFP).
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