Register for Teen 2 Success

Please complete the form below.
For participants ages 13–17, a parent or legal guardian must complete the registration form.
Participants ages 18–19 may complete the form themselves.

August 10th-August 14th

Participant's Full Legal Name *
Preferred Name
Date of Birth *
Age *
Participant Age Group *
Grade Level *
School Name *
City & State *
Participant Email
Participant Phone Number
Parent/Legal Guardian Full Name: *
Relationship to Participant *
Parent/Legal Guardian Email & Phone Number *
Parent/Legal Guardian Address *
Emergency Contact Name & Phone Number *
Emergency Contact Relationship to Participant *
Authorized Pickup Persons *
Is the participant allowed to leave independently at the end of the program/event? * *
Medical, Allergy, Accessibility, or Safety Information
Emergency Medical Permission In the event of an emergency, I authorize KYHOM INC staff, volunteers, or program representatives to seek emergency medical care for the participant if I cannot be reached. I understand that KYHOM INC will make reasonable efforts to contact the parent/legal guardian and emergency contact listed on this form *	Yes, I give emergency medical permission. No, I do not give emergency medical permission.
What do you hope to gain from Teen 2 Success? *
Is there anything you want KYHOM INC to know before the program begins? *
Program Expectations and Code of Conduct Teen 2 Success is a youth-centered program created to support confidence, leadership, healing, education, personal growth, and positive community connection. By registering, the participant and parent/legal guardian understand and agree that the participant is expected to: Follow all program rules, staff instructions, safety guidance, and posted directions. Treat staff, volunteers, speakers, partners, and other participants with respect. Avoid threatening, bullying, harassing, discriminatory, violent, unsafe, or inappropriate behavior. Respect the privacy, experiences, and personal boundaries of other participants. Participate in a safe and age-appropriate manner. Notify staff if they feel unsafe, uncomfortable, sick, overwhelmed, or need support. KYHOM INC reserves the right to remove a participant from the program, workshop, event, or activity if the participant’s behavior is unsafe, disruptive, threatening, harassing, discriminatory, inappropriate, or harmful to themselves or others. *	I have read and agree to the Teen 2 Success program expectations and code of conduct.
5-Day Commitment Agreement Teen 2 Success is designed as a committed program experience. I understand that participants are expected to attend all scheduled program days, arrive on time, participate respectfully, and notify KYHOM INC as soon as possible if they cannot attend. *	I understand and agree to the Teen 2 Success attendance and commitment expectations.
Parent/Guardian Consent — required only for minors: I am the parent/legal guardian of the minor participant listed above. I give permission for the participant to take part in Teen 2 Success programming, workshops, events, activities, discussions, and related KYHOM INC youth-centered programming. I understand that participation is voluntary. I understand that some topics may include personal growth, confidence, safety, prevention, advocacy, community support, healthy relationships, leadership, trauma awareness, or other sensitive subjects. I understand that KYHOM INC programming is not a replacement for medical care, therapy, legal advice, or crisis services. *	Yes, I give permission for the participant to participate in Teen 2 Success. Not applicable — participant is age 18–19.
Participant Consent for Ages 18–19 Required for participants ages 18–19. Parents/legal guardians of participants ages 13–17 may select “Not applicable.” I am age 18 or 19, and I am registering myself for Teen 2 Success. I understand that participation is voluntary, and I agree to follow all Teen 2 Success program expectations, safety rules, and code of conduct. *	Yes, I am age 18 or 19 and I consent to participate. Not applicable — participant is under age 18.
Event Rules, Risk, and Liability Release By registering, I understand and agree that participation in Teen 2 Success activities is voluntary. I understand that activities may include group discussions, workshops, indoor or outdoor activities, guest speakers, community events, transportation by parent/guardian or approved parties, and other related programming. I understand that participation may involve risks, including but not limited to emotional discomfort, physical activity, illness, accidents, travel-related risks, property loss, or unexpected incidents. To the fullest extent permitted by law, I voluntarily assume the risks connected with the participant’s involvement in Teen 2 Success and related KYHOM INC activities. To the fullest extent permitted by law, I release, waive, discharge, and hold harmless KYHOM INC, its directors, officers, employees, volunteers, organizers, representatives, partners, sponsors, vendors, agents, successors, and assigns from claims, damages, losses, costs, or expenses arising out of or related to the participant’s involvement, except were prohibited by law. I understand that laws regarding releases and waivers for minors vary by state, and this release applies only to the fullest extent permitted by applicable law. *	I have read, understand, and agree to the safety, risk, and liability terms.
Photo and Media Release KYHOM INC may take photos, videos, livestreams, interviews, or other recordings during the event for nonprofit outreach, education, social media, website content, newsletters, press, fundraising, event promotion, and future awareness campaigns. Media Consent: *	Yes, I give KYHOM INC permission to use my photo, video, voice, name, and likeness. Yes, as parent/legal guardian, I give KYHOM INC permission to use the minor participant’s photo, video, voice, name, and likeness.
Parent/Guardian Communication Permission: I give KYHOM INC permission to contact the parent/legal guardian about Teen 2 Success updates, reminders, scheduling, resources, and program information. *	Yes, KYHOM INC may contact me by email, phone, and/or text about Teen 2 Success.
Participant Acknowledgment I understand that Teen 2 Success is a safe and supportive program. I agree to respect myself, other participants, KYHOM INC staff, volunteers, speakers, and community members. I agree to follow program rules and ask for help if I feel unsafe, uncomfortable, or need support. *	Yes, KYHOM INC may contact me by email, phone, and/or text about Teen 2 Success.
Participant Name *
Participant Electronic Signature *
	Final Signature By signing below, I confirm that the information provided is true and complete. I understand that typing my name serves as my electronic signature. I confirm that I am the parent/legal guardian of the participant listed above and that I have read and agree to all required registration, consent, safety, risk, media, emergency, and signature terms. *
Name of Person Signing *	Parent/legal guardian for ages 13–17 Participant for ages 18–19
Relationship to Participant *	Self, age 18–19 Parent/legal guardian Other
Participant or Parent/Legal Guardian Name: *
Participant or Parent/Legal Guardian Electronic Signature: *
Date of Signature *
	I have read and agree to all required Teen 2 Success registration, consent, safety, emergency, risk, media, and signature terms. *

Speaker For The Weeks

KEEP YOUR HANDS OFF ME, Inc.

info@keepyourhandsoffme.org

Main: 910-833-5119

910-233-6926

Physical Address:
1506 Market Street, Suite A/B
Wilmington, NC 28401

Mailing Address:
PO BOX 3024
Wilmington, NC 28406