Youth OUTLOUD at HHCF - New Youth Intake Form 
Important: This form is for YOUTH wishing to attend a Youth OUTLOUD meeting or event. Parents/Guardians, please support your youth in completing this form allowing them to complete as much of the form as possible on their own. (All information should describe youth, not parents/guardians.)

This membership form is for youth aged 11 - 17 who wish to participate. If you are older than 17, please contact the center for more information about services for folks over age 17 (youthoutloud@harriethancockcenter.org). Note: If any reason presents for us to question information provided about age, we may request verification through legal ID. 

A staff member will contact youth after the Intake Form is complete. Please include contact information (email and phone number) that is safe for a staff member to use to contact you. 

THANK YOU in advance for your patience and diligence in completing the form with accuracy. 
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Email *
How did you learn about Youth OUTLOUD *
What is your date of birth (include year)? *
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What is your current age? *
What is your chosen first name (the name you would like to be called)? *
What is your chosen last name (the name you would like to be called)? *
Is your legal name the same as your chosen name? (Write Yes.) If not, please write your full legal name, which will be kept private. 
Pronouns are used as a way to identify or refer to someone. Common examples of pronouns include they/them/theirs, she/her, and he/him, among many others. What are your pronouns? *
Required
What is a safe phone number a Youth OUTLOUD staff member can you to reach you?  *
What is your email address? (for youth) This is the email we will use to send you program information. Double check for accuracy! *
Social media accounts: If you'd like, please provide account names/screen names we can use to reach you. (Include the name of the social media platform)
Please list your address including city, state, and zip code. If you do not currently have a permanent address or wish not to share this information, please provide the zip code where you spend the majority of your time.  *
What is your ethnicity or racial identity? (select all that apply) *
Required
Are you Hispanic or Latino/Latinx?
Clear selection
Sexual orientation refers to who you are physically, emotionally, and/or romantically attracted to. When you think of your sexual, romantic, and/or emotional interests, select any of the terms that describe you.   *
Required
Do you identify with being Intersex? Intersex is a general term used for a variety of situations in which a person is born with reproductive or sexual anatomy that does not fit the typical binary notions of male or female bodies. More Information about Intersex People
Clear selection
Gender Identity refers to how you see yourself. It is an internal and personal experience. When you think of your gender identity (or expression), select any of the terms that describe you.  *
Where do you go to school?  *
What grade are you in currently? (If completing during the Summer, what grade are you going into?) *
Are you currently employed? *
Have you ever been in Foster Care? *
What is your current living/housing status?  *
Do you qualify for free or reduced lunch? *
Do you have any medical conditions we need to know about? If you are a person with a disability or medical condition and require a reasonable accommodation, please let us know what support services you need here. (If no, write none.)
Do you have reliable transportation to group meetings? *
What are your interests? What type of activities do you enjoy? We want to make sure we create activities for everyone to enjoy.  *
Emergency Contact Information
Please provide contact information for someone we can reach in case of an emergency or if a serious concern arises. Please try to include information for at least one parent/guardian or a safe adult in your life. 
1. Emergency Contact Name *
1. Emergency Contact Relationship *
1. Emergency Contact Phone Number *
1. Emergency Contact Email *
2. Emergency Contact Name
2. Emergency Contact Relationship
2. Emergency Contact Phone Number 
2. Emergency Contact Email
When contacting your emergency contact(s), what name should we use for you?  *
When contacting your emergency contact, what pronouns should we use for you?  *
Finally! Review and confirm agreement to our SPACE AGREEMENTS
SPACE AGREEMENTS

No bullying or harassment (this includes cyber bullying and leaving people out intentionally)

No drugs or alcohol (including paraphernalia) in our facilities or shown in virtual group

Practice Active Listening: Give your attention to people when they are speaking. Listen to HEAR what someone is saying before responding or interrupting. Give people space to talk about their experiences.

Don’t Yuck My Yum! When someone shares something they like, don’t knock it just because you don’t. This adds nothing of value to the conversation. To each their own! (unless it’s oppressive)

Own Your Impact: If you do hurt someone, own your impact no matter the intention. Practice taking accountability and apologizing. Saying "I'm sorry" can go a long way.

Vegas Rule “What’s said here stays here, what’s learned here leaves here!” Respect confidentiality. Don’t share anyone’s personal story or information without consent. This does not include experiences that have to be reported, such as experiences of abuse or neglect. Also, some people may use pronouns or names here that they may not want used outside of the space.

Move Up, Move Up! Be aware of how much space you take up in the conversation. If you typically talk a lot, try moving up your listening skills. If you are someone who doesn’t usually speak, try speaking up more. We want everyone to have space to participate in the group.

If a conversation is triggering or upsetting and you wish to leave the group, please tell a facilitator so they can assist you and follow up with support.

We take language about death seriously. Although we do discuss issues of self harm and suicide, we should not be casually mentioning suicide and death in a joking manner. Before making certain statements about death, consider how this can be a trigger for the rest of the group and for yourself.

We encourage you to tell a facilitator if you are being bothered, harassed, or made uncomfortable by someone else in the group.

Be mindful of your language (do not use oppressive or vulgar language that is disrespectful). Respect each other, volunteers, the space, and yourself.

One person in the restroom at a time.

Clean up after yourself: clean up spills, throw away trash, help put up chairs and other supplies.
Review and agree to our SPACE AGREEMENTS! *
DUTY TO WARN/DUTY TO PROTECT: 
If any representative of YouthOUTLOUD or the Harriet Hancock Center believes I am in physical or emotional danger or I am a danger to another person, I understand the representative is required by law to contact medical or law enforcement personnel to prevent harm to me or another person. Additionally, the representative may contact the person in danger. 
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CONFIDENTIALITY & MANDATED REPORTING:
I understand that discussions between myself, YouthOUTLOUD/Harriet Hancock Center, and referred programs, as well as any records are confidential with the exceptions noted below. No information will be released without my written consent unless mandated by law. Possible exceptions to confidentiality include but are not limited to the following: abuse of an other person, sexual exploitation, AIDS/HIV infection and possible transmission, criminal prosecutions, child custody cases, suits in which the mental health of a party is in issue, situations where the staff has a duty to disclose, or where, in the staff's judgment, it is necessary to warn or disclose. Some YouthOUTLOUD/Harriet Hancock Center staff members are Mandated Reporters. Mandated Reporters must report suspected child abuse or neglect to the South Carolina Department of Social Services. Read more information here: https://dss.sc.gov/child-well-being/mandated-reporters/
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Statement on COVID-19 and in person events and meetings
It is very important that we do our part to restrict the spread of disease while sustaining programming for our community. Please understand that each person who attends in person events are doing so at their own risk. YouthOUTLOUD/Harriet Hancock Center is not responsible for a participant's possible exposure to COVID-19 while participating in our programs. All people who wish to attend in-person events are encouraged to be vaccinated. Social distancing, hand washing, using hand sanitizer, and not sharing personal items is encouraged. We also sanitize our meeting areas before and after meetings. If you suspect that you have been exposed to COVID-19 or are certain you are ill with COVID-19 or another contagious illness, please do not come to in-person programming until you have fully recovered. 
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PHOTO RELEASE
I hereby grant permission to Youth OUTLOUD and the Harriet Hancock Center to use photographs and/or video of me taken at Youth OUTLOUD events in publications, news releases, online, and in other communications related to the mission of Youth OUTLOUD.
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Conditions for permission to use photo/video. (If selected above)
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