Upopolis Common Grounds Application
During the Fall of 2023 and Winter of 2024, the Upopolis team will be hosting sets of virtual meet-ups called Common Grounds for teens (ages 10-18) living with specific medical diagnoses and conditions, siblings, the youth of adult patients, and youth navigating grief. If you are a teen interested in signing up for one of these events, please complete the application below. Then one of the Upopolis child life specialists will reach out to you via email with more details (date, time, login links, and a note about what to expect).  In this application, please use an email that you (the youth) will check regularly.
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Your emal address (the youth checks ofter) *
Youth First Name: *
Youth Last Name:  *
Preferred Pronouns:
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Date of Birth *
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DD
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YYYY
Age *
Mailing Address, including postal code (if you would like to recieve some Upopolis swag or programming supplies e.g journal): *
Which Common Grounds meet ups would you like to join: *
Emergency Contact First and Last Name: *
Emergency Contact Phone Number: *
How did you hear about Upopolis? *
Please share anything else that might be helpful for us to know before connecting with you during the Common Grounds meet-ups. E.g. accommodations needs like closed captioning.
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