Youths Left Behind Participant Application
 "To create a respectful and responsible community for our youths that have been affected by mass incarceration of parents, gun violence, and lack of comprehensive mentorship." Peer Group Empowerment is a continuing 8-week course designed to help youths overcome past mistakes and reach new horizons. Participants will be able to address challenges they face daily and learn how to overcome them with the help of their peers, while under guidance from mentors. By signing this form, parties agree the children will obey all rules in group meetings, attend weekly sessions, and write a 200-word essay on what they have learned from Peer Group Empowerment in order to graduate from the class. Parties acknowledge and agree to allow photos and videos to be open to the public, as well as data to be collected and reported. 

Please fill out the application in its entirety and a YLB team member will be in contact with you shortly. Also please be sure to hit the submit button when completed.
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Email *
How did you hear about our program? 
Youths Left Behind Corp.
Full Name *
Date of Birth *
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Address *
Phone Number *
Email *
School *
Grade *
Student ID Number (Put N/A if Not Applicable) *
Allergies (Put N/A if Not Applicable) *
Any Chronic Health Conditions (If no, insert N/A or None)
(Asthma, Epilepsy, etc)
 *
PARENT/GUARDIAN INFORMATION
Please have your parent or guardian fill out the rest of the form and make sure all questions are answered or the form will not submit at the end.
Parent/Guardian Name *
Parent/Guardian Phone Number *
Parent/Guardian Email *
Parent/Guardian: By typing your name in the space provided below, you hereby authorize and consent to your child's participation in the Youths Left Behind Program. By entering your name below, you acknowledge and agree that it serves as a digital signature, indicating your acceptance of all rules and guidelines outlined at the beginning of this form. Please note that you may be required to provide a physical signature on a printed document at the commencement of your child's involvement in YLB's program. *
Parent/Guardian: Please enter the date you digitally signed and are submitting this application. *
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