Application – Youth Empowerment Program

Y.E.P. (YOUTH EMPOWERMENT PROGRAM) APPLICATION FORM (2023-2024)

Student and Family Information
STUDENT QUESTIONS (parent/guardian questions below)
Student Name*
First Last
Grade this year*
Your School*
Student Date of Birth*
MM slash DD slash YYYY
Student Address*
Street Address City ZIP Code
Student Email (whichever address you are most likely to check)
Student Phone Number
If available
Which of the following activities would you be interested in? (check all that apply to you)
- Group trips to places like Action City, the bowling alley, etc.
- Singing at the Senior Center (at Christmas/ possibly other times)
- Writing scripts for plays or online videos
- Performing in online videos
- Performing in a skit for elementary students
- Drawing (Helping to develop posters, online content, etc.)
- Helping to create content for the group website and social media (Trivia games, Memes, etc.)
- Helping others in my school or community (helping senior citizens by raking lawns, fundraisers, etc.)
- Learning about issues related to drugs and alcohol
- Learning about other issues such as bullying, anxiety, depression, etc.
- Sharing what I’ve learned with others (friends, parents, teachers, school board, etc.)
- Hanging out with friends
- Making new friends
- Eating snacks
- Improving my speaking skills
- Improving my leadership skills
- Becoming a leader in the group
- Playing games
- Being outside
Feel free to list any other ideas you think might be a good fit for the group:
Are there any skills or abilities you have that you think would be helpful to the group? (Please feel free to brag about yourself for a bit!)
Are there any other after school sports or clubs you plan to be a part of this school year? If yes, list below:
PARENT/GUARDIAN QUESTIONS
Primary Parent/Guardian Name*
First Last
Relationship to student*
- Mother
- Father
- Guardian
- Other
Home or Cell Phone Number*
Work Phone Number
Email*
Secondary Parent/Guardian
First Last
Relationship to Student
- Mother
- Father
- Guardian
- Other
Home or Cell Phone Number
Work Phone Number
Email
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)
Student Gender
- Male
- Female
- Other
- Transgender
- Non-binary
- Gender Non-conforming
- Self Identify
- Prefer not to answer
Student Ethnic Origin
- Asian
- Native Hawaiian or Other Pacific Islander
- Black or African American
- White or Caucasian
- Hispanic or Latino
- Native American or Alaska Native
- Biracial or Multiracial
- Other
- Prefer not to Answer
During the past year, has your child lived in stable housing (i.e. safe and not temporary)?
- YES
- NO
- Prefer not to answer
During the past year, has your child experienced homelessness?
- YES
- NO
- Prefer not to answer
During the past year, have you been able obtain services to meet your child’s health needs (physical, mental or emotional?)
- YES
- NO
- Prefer not to answer
If you answered no to the last question, please note (below) any barriers that kept you from the needed service (i.e. on a waiting list, didn’t like the doctor/counselor, cost, transportation, other?)
PERMISSION FORM (2023-2024)
PROGRAM DETAILS
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.
SCHOOL BEHAVIOR AND DISCIPLINE POLICY
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.
POLICY ON GRADES AND LEAVING SCHOOL
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.
YOUTH EMPOWERMENT PROGRAM CANCELLATION POLICY
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.
TRANSPORTATION
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
Please note who is authorized to pick up your child from programming*
Name/Phone # Relationship to student
Second person authorized to pick up your child from programming
Name/Phone # Relationship to student
CONSENT TO PHOTOGRAPH/RELEASE INFORMATION*
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.
- I permit Arbor Place, Inc. to use photographs or video clips of my child in any of the following- brochures, posters, media articles, TV news reports, the official Y.E.P. website and social media sites, and in presentations for the program.
- I do not permit Arbor Place, Inc. to use photographs or video clips of my child in any of the following- brochures, posters, media articles, TV news reports, the official Y.E.P. website and social media sites, and in presentations for the program.
MEDICAL OR PERSONAL NEEDS INFORMATION*
Does your child suffer from allergies, asthma, other medical conditions, learning disability, etc.?
- Yes
- No
If yes to the question above, please describe below.
Consent for Emergency Treatment*
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.
- Yes
- No - Please note, checking "No" means we will not be able to seek medical care for your child in case of an emergency if we can't reach you by phone.
Contact Information for Student's Primary Physician
Doctor's Name Doctor's Phone Number
Consent*
By signing, I certify that I have fully read, understand and agree to the program information and expectations noted in this Permission Form and hereby provide permission for the student listed on this form to participate in the Youth Empowerment Program.
I give permission for my child to participate in YEP
Parent/Guardian E-Signature*
Name Date

Youth Empowerment Program

Made Possible by the Brighter Futures Initiative (BFI)

Y.E.P. (YOUTH EMPOWERMENT PROGRAM) APPLICATION FORM (2023-2024)

Student and Family Information

STUDENT QUESTIONS (parent/guardian questions below)

PARENT/GUARDIAN QUESTIONS

PERMISSION FORM (2023-2024)

PROGRAM DETAILS

SCHOOL BEHAVIOR AND DISCIPLINE POLICY

POLICY ON GRADES AND LEAVING SCHOOL

YOUTH EMPOWERMENT PROGRAM CANCELLATION POLICY

TRANSPORTATION