• Student and Family Information

  • STUDENT QUESTIONS (parent/guardian questions below)

  • MM slash DD slash YYYY
  • If available

  • Demographic Questions (Our funder requests that we ask for the following information. Completed applications will be kept in a locked cabinet, and only composite data (numbers) will be provided to our funder. No names/individual identifying data will be shared. You can also select “prefer not to answer” for any item you desire. If you have questions, please contact Sherry Berg, [email protected] or 715-235-4537 ext. 220)

  • PERMISSION FORM (2023-2024)


    Y.E.P. is an after-school program that is being offered by Arbor Place, Inc. in collaboration with your school district. The program will strive to address some of the pressures that middle school students can experience by teaching participants about the risks of using alcohol and other drugs. They’ll also learn about issues such as how to deal with conflict and prevent bullying behavior, building positive friendships, making healthy choices, and public speaking skills. The group will meet once a week after school, with an initial goal of learning about these issues and bonding as a team. Eventually they could teach others what they have learned by putting on a skit for preschool and elementary students, contributing to social media pages for their peers, or even meeting with parent groups and elected officials to share their concerns.

    Y.E.P. is a voluntary program, provided in collaboration with your school district. Program participants are expected to behave according to the school's established behavior policies during Y.E.P. meetings and sponsored activities or events. A student may be asked to take a break from an activity if he or she is misbehaving or acting inappropriately. If the problem is severe or persistent, such as continuing after warning(s) have been given, a Y.E.P. staff member will contact the student’s parent/guardian and/or consult with the school administrator for assistance. If a student is suspended from school, he/she will not be allowed to participate in Y.E.P. meetings, activities or events during the suspension.

    Students participating in Y.E.P. may have opportunities to sign up for presentations and activities that take place during their school day. They are never required to participate in such presentations or events. Parents/guardians may also request at any time that their child not participate on projects that cause a loss of any class time. They may also withdraw permission for their child’s involvement in the program for poor grades or any other reason.

    The Y.E.P. schedule will fit within the school schedule. Meetings and/or events will not be held on days that your school cancels classes due to weather or other unexpected situations. Y.E.P. meetings and/or events might be held on days that your school cancels classes for other reasons, such as holiday break, staff in-service, etc. However, when this occurs, parents/guardians will receive notice at least two weeks in advance and have the option of allowing, or not allowing, their child’s participation.

    A parent/guardian will be responsible for picking their child up or making arrangements for their child to be picked up by no later than 15 minutes after the close of a meeting, activity or event. NOTE- if transportation costs related to picking your child up after the meetings is a barrier, we do have some funding available to help pay for gas. Please contact Sherry Berg, Manager of Prevention Services, for details- [email protected] or 715-235-4537 ext. 220
  • The Youth Empowerment Program (Y.E.P.) Staff or members of local media may take photographs, videotape or audio record Y.E.P. participants as part of the program. Students may also choose to submit pictures or videos as part of our online program. This documentation may be used in brochures, posters, media articles, TV news reports, the official Y.E.P. website and social media sites, and in presentations for the program. As such, materials remain the property of Arbor Place Inc. and students/parents/guardians are not provided any compensation or payment for their use.
  • Does your child suffer from allergies, asthma, other medical conditions, learning disability, etc.?
  • I authorize Arbor Place, Inc., and its designated staff to consent, on my behalf, to contact any emergency medical/hospital care or treatment to be rendered upon the advice of any licensed physician. I agree to be responsible for all necessary charges incurred by any hospitalization or treatment rendered pursuant to this authorization.