Register and Permission Form

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Register & Permission

Student's Name(Required)

First Last

Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone(Required)

Email(Required)

School(Required)

Age(Required)

Grade(Required)

Gender(Required)

Male

Female

Preferred Pronoun(Required)

Race(Required)

County(Required)

T-shirt Size

Social Media (active on)(Required)

Facebook

Instagram

Twitter

SnapChat

TikTok

Interests and Hobbies(Required)

Parent/Guardian's Name(Required)

First Last

Parent/Guardian's Email(Required)

Parent/Guardian's Phone(Required)

Why would you like to be in the Resilient Teen Program? Write a short essay - 300 words maximum.(Required)

Parent Permission(Required)

I give permission for my teen to participate in the Resilient Teen Project and to provide the necessary access to a computer and the internet, understanding the risk associated with online communication. Sensitive topics will be discussed in programming. All care will be given to protect your child’s personal information as part of this project.

Photo Permission(Required)

Yes

I also give my permission for my child's picture to be used in the Resilient Teen Project final report.

Parent Signature(Required)

I expressly release Augusta University or Georgia Family Connection from any liability arising in any way from my child’s participation in this volunteer project. You may revoke this permission at any time in writing.

Student Commitment(Required)

I agree to participate fully in the scheduled Resilient Teen Project sessions and to do my best to be an active participant.

Student Signature(Required)

Home
About
Program
Summit
Meet Our Team
Resources
Connect

Home
About
Program
Summit
Meet Our Team
Resources
Connect
Connect