HealthyC.L.I.M.B.E.R.S. Applicatio

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Welcome CLIMBERS!

We are excited to have you join our program and can't wait to meet you! To join HealthyC.L.I.M.B.E.R.S. you must complete this application and submit it. Once submitted, a confirmation email will be emailed to you along with the Zoom meeting link to the first meeting.

**Note: We ask that all participants under age 18 have a parent or guardian complete and sign this application before submission.

**Program information and frequently asked questions about HealthyC.L.I.M.B.E.R.S**

What is HealthyC.L.I.M.B.E.R.S?

HealthyC.L.I.M.B.E.R.S is a youth empowerment program hosted by Resident of Color Collective (ROCC) in collaboration with Dakota Child and Family Clinic (DCFC). Dakota Child and Family Clinic saw the need to create a judgment-free space for emerging young adults ages 13 to 24 who identified as BIPOC to learn life skills and thrive collectively as community leaders.

HealthyC.L.I.M.B.E.R.S was co-created to empower and equip emerging young leaders with leadership and life skills to establish their ideal healthy community.

HealthyC.L.I.M.B.E.R.S’ Youth Empowerment Program mission

· Provide a judgment-free and safe space for emerging BIPOC young leaders to hold open conversations from a place of curiosity to identify self-love, establish safe boundaries, practice healthy communication and to respect other’s choices.

· HealthyC.L.I.M.B.E.R.S seeks to empower participants to speak transparently and question information they received, to not be misinformed- specifically when it comes to their outlook on healthy relationships, leadership and self-development.

· HealthyC.L.I.M.B.E.R.S will consist of a youth program and parents and caregivers' education & support workshop.

How often will HealthyC.L.I.M.B.E.R.S meet?

· HealthyC.L.I.M.B.E.R.S will meeting weekly starting mid-April to the end of July virtually and in-person.
· Parents and Caregivers’ Education Workshop will meet quarterly in person at Wentworth Library and virtually by request.

If you have questions or concerns, please email the program coordinator Amirillis Vang at amirillis@dakotachildandfamily.org or call 651-209-8640.

Please list the name of your school, and what grade you are in? (optional)

Please select your ethnicity.

Black/African American

American Indian/Alaska Native

Asian American

Caucasian

Hispanic/Latinx

Native Hawaiian/Pacific Islander

Two or more races

Pefer not to say

Other:

What are your pronouns? *

she/her/hers

he/him/his

they/them/theirs

ze/hir/hirs

I prefer not to say

Other:

Please provide an email address. *

What is the youths last name? *

Please select the option that describe you. (Check all that apply) *

I am a middle school student.

I am a high school student.

I am a college student.

I am currently not attending school at this time.

Required

What is your age range? (optional)

Under 12 years old

13 to 15 years old

16 to 18 years old

19 to 21 years old

22 to 24 years old

Clear selection

Please select your gender identity.

Female

Male

Intersex

Non-Binary

Transgender

I prefer not to say

Other:

Please provide a contact phone number to reach you at. *

What is your preferred contact method? *

phone

text

I have no preference

Required

What is the youths first name? *

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