Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417 Email: www.realtalknv.com Pre-‐Registration Form Real Talk is a free charitable program that is designed to hit home with at-risk youth and provide the resources, funding, and support needed for Southern Nevada adolescents to participate in extra-curricular activities of their choice. Please refer to the calendar on the Real Talk website for the date, time, and location of each Change One Meeting. There will be a maximum of 50 participants for each Change One Meeting. Should you not make the first group of 50, your registration will automatically be placed on the following month’s registration calendar. You will receive a confirmation email in response to your request. Parent/Guardian:_______________________________________________ Parent/Guardian Email: _________________________________________ Address: ___________________________________________________ Phone Number: (_____) __________________________ Participant Name:____________________________________________ Age: ______ Preferred Change One Meeting: Month:_______________ Year: _______________
Eligibility Criteria/Requirements For Youth Participation v All at-‐risk youth ages 8-‐18 v Attend all three Change One meetings v All participants must attend all three meetings in order to graduate from the Program and to be able to participate in extra-‐curricular activities provided v It is recommended that the participant complete the meetings sequentially v If a participant misses a meeting, he/she will have the opportunity to attend the following meeting v Participant has up to six months to complete the three required meetings v Should the participant fail to meet the three meeting requirement in a six month period, he/she will have to start over and attend the initial meeting v Complete a before and after survey v Participate in viewing the community support booths v Cell phones and all other social media devices will not be permitted inside the meetings v Social media devices are not to be accessed during the meeting; you will be asked to leave the meeting if you do so v Address the members of the Real Talk Youth Impact Program as “Mr./Mrs./ or Ms.” v No hats v No gang attire v No sex offenders v All participants will be required to wear designated name tags at all meetings to reflect participant’s program phase v All participants will sign a waiver agreeing not use the Real Talk meeting as a recruiting ground for inappropriate behavior
Participant Requirement For Change One Meetings v Participants will be provided a numbered name tag v Name tags will be color coded to identify first, second, and third time attendee v Participants will be given a program brochure detailing who the speakers will be for each Change One meeting v During the Change One meetings participants will address the members as “Mr./Mrs./Ms.” v Upon completion of the participant’s third meeting, he/she will be provided a program certificate and Program T-‐shirt v Each participant will sign a waiver regarding an agreement not to use the Program as a recruiting ground for inappropriate behavior v Each participant will fill out an initial and end of program survey
Parent/Guardian Requirements v Complete registration form v Complete a before and after survey v Sign youth participation waiver v v Attend the first and third Change One meetings v Sign authorization to release confidential information v Sign photo/video release v Sign a waiver for extra-‐curricular activity that the participant has selected v Agree that members who are currently on federal supervision shall not communicate or otherwise have contact with the participant outside of the Program, in person or through any form of social media v Any parent/guardian who desires their participant to continue to have contact with a member who has expired from supervision must sign a waiver
Eligibility Criteria For Youth Rewards and Incentives v Participant must not be in violation status v Maintain a 2.0 average in school v Be obedient, respectful to parent/guardian, speakers, and other participants v Attend all three mandatory Change One meetings v Attend selected program/extra-‐curricular activity regularly v Complete any court ordered community service v Attend school regularly v Shall be gang-‐free v
Shall be drug-‐free