Real talk v3 cube 3 1 word (2)

Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417 Email: realtalknv.com Registration Form Parent/Guardian:_____________________________________________________ Email: _____________________________________________________________ Phone Number:(____)__________________________________ Participant Name:____________________________________________ Age: ________ Grade: _______ Participant’s Ethnicity: African-­‐American _______ Hispanic ______Caucasian______ Asian_______ Pacific Islander _______ Other_______ Parent/Guardian Annual Income: ______________________________ Is participant currently under a juvenile court order: Yes ____ No _____ Is participant under Probation/Parole: Yes ____ No _____ If not, is participant voluntarily attending this program: Yes _____ No ____ Presenting Problems: Substance Abuse ___ Alcohol ___ Drugs ____ Gang Involvement: Yes____ No____ Unknown ______ Other: _______________________________________ The participant will attend all three required Change One meetings: Yes _____ No _____ T-­‐Shirt size: Small ____ Medium______ Large______ XL _____ XXL _____ XXXL________

Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417 Parent/Guardian Waiver For Youth Participation

I _____________________________am the parent/guardian of ________________________ and I give permission for ________________________ to participate in the Real Talk Youth Impact Program. I understand that the Program utilizes former and present federal offenders that will be sharing their personal experiences about their lives. I understand that the Program’s intent is to keep the members stories as authentic as possible and to keep the content of their stories as professional as possible. However, I understand that there may be instances wherein the authenticity of their stories may be offensive to me and my child. I agree to permit___________________________ to attend the Program. I understand and agree that I fully and forever release, acquit, waive and discharge liability of the Real Talk Youth Impact Program for any of the content or personal information released throughout the duration of the program.

The parent or guardian of the undersigned juvenile hereby consents and authorizes the undersigned juvenile to participate in the Real Talk Youth Impact Program.

Print Name: ______________________________________________ __________ Participant Date

Signature: _____________________________________________ __________

Participant Date

Print Name:______________________________________________ ___________

Parent/Guardian Date

Signature: ____________________________________________ ___________ Parent/Guardian Signature Date

Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417

Parent/Guardian Authorization To Release Confidential Information

I _____________________________am the parent/guardian of ________________________ and I give permission for ________________________ to participate in the Real Talk Youth Impact Program. I understand that the Program has numerous partnerships with outside agencies in order to effectively run the Program. I understand that the partnerships will need to obtain personal information regarding__________________________ in order expedite the process of future services/activities that__________________________ elects to participate in. With this understanding, I agree to allow the Program to share confidential information regarding ________________________________ to any other agencies or third parties involved with the Program. Additionally, I understand and agree that I fully and forever release, acquit, waive and discharge liability of the Real Talk Youth Impact Program for any of the content or personal information released throughout the duration of the Program.

The parent or guardian of the participant hereby consents and authorizes the Real Talk Youth Impact Program to release content or personal information to other agencies or third parties.

Print Name:______________________________________________ ___________

Parent/Guardian Date

Signature: ____________________________________________ ___________ Parent/Guardian Signature Date

Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417 Photo/Video Release

By registering for the Real Talk Youth Impact Program, I understand that the Program participants may be subject to video recordings and photographs for the sole purpose of marketing the Program and the Program’s services.

Therefore, I, ,the parent/guardian of agree to allow the Program to use any photographs/video footage taken of me or at any Program event, or other agencies or third parties associated with the Program.

The parent or guardian of the participant hereby consents and authorizes the Real Talk Youth Impact Program to release photographs or video footage from the Program event, other agencies or third parties associated with the Program.

Print Name:______________________________________________ ___________ Parent/Guardian Date

Signature: ____________________________________________ ___________ Parent/Guardian Signature Date

Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417 Participant Waiver

I _______________________________, agree to participate in the Real Talk Youth Impact Program. I also agree that my behavior during the Program will be of good character.

Additionally, I agree that I will not use the Program as a platform to recruit other participants in engaging or displaying negative behavior. I also understand that should any inappropriate behavior be displayed or witnessed during the Program, I will be removed from the Program. Finally, I understand that the option of returning to the Program at a later date will be at the discretion of the Real Talk Program members board.

The parent or guardian of the undersigned juvenile hereby consents and authorizes the undersigned juvenile to participate in the Real Talk Youth Impact Program.

Print Name: ______________________________________________ __________ Participant Date

Signature: _____________________________________________ __________

Participant Date

Print Name:______________________________________________ ___________

Parent/Guardian Date

Signature: ____________________________________________ ___________ Parent/Guardian Signature Date

Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vega, NV 89106 Phone Number: 702-625-2417 Parent/Guardian Waiver Allowing Contact With Former Members I_________________________________am the parent/guardian of __________________________ and have given prior permission for ________________________ to participate in the Real Talk Youth Impact Program. I recognize that the Program does not encourage ongoing contact between members and participants during the Program or following the member’s expiration from supervision. Regardless, I give permission to allow _________________________ to have contact outside of the Real Talk Program with any member who is not currently under federal supervision.

Additionally, I understand and agree that I fully and forever release, acquit, waive and discharge liability of the Real Talk Youth Impact Program should any misconduct from a former member that I have elected ______________________________ to associate with outside of the Program.

The parent or guardian of the undersigned juvenile hereby consents and authorizes the undersigned juvenile to associate with previous federal offenders outside of the Real Talk Youth Impact Program.

Print Name: ______________________________________________ __________ Participant Date

Signature: _____________________________________________ __________

Participant Date

Print Name:______________________________________________ ___________

Parent/Guardian Date

Signature: ____________________________________________ ___________ Parent/Guardian Signature Date

Real Talk Youth Impact Program

840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417

Participant Initial Survey

Name:_________________________________

1. Who inspires you and what are their specific characteristics that inspire you?

2. What things in life are you passionate about?

3. What have you done that makes you feel proud?

4. Do you have a talent that you do not use and if so, what is it?

5. Do you have any future goals?

6. Where do you see yourself in a year?

7. What would you like to get from the Program that could assist you with having a positive future?

Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417 Parent/Guardian Initial Program Survey Participant Name: ___________________________

1. What do you hope participant will get from attending the Real Talk Program?

2. Are you a single parent? Yes or No

3. What is your relationship to the participant?

4. How old is the participant ?

5. Does the participant have children? Yes No Not sure

6. Does participant associate with negative peers? Yes or No

7. Is participant involved in a gang? Yes No Not sure

8. Does participant abuse drugs? Yes No Not sure Unknown

9. Circle any of the following that participant lacks: Positive role model Spiritual guidance Direction Respect Goals Dreams Talent Motivation Self-­‐esteem Mentors Positive peers

10. What changes would you like to see in the participant?