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YLAB Registration
YLAB Registration
"
*
" indicates required fields
Who is the person completing this form?
*
Youth
Parent/Guardian
Youth Information
Youth's Full Name
*
First
Last
Youth's Preferred Name
Youth's Birthdate
*
MM slash DD slash YYYY
Youth's Pronouns
*
She, her, hers
He, him, his
They, them, theirs
Other
Youth's Gender
*
Male
Female
Non-binary
Other
Youth's Ethnicity
*
African
American Indian/Alaska Native
Asian
Black/African American
Middle Eastern
Native Hawaiian/Pacific Islander
Slavic
White/Caucasian
Unknown
Prefer Not to Answer
Please, check all that apply.
Youth's Grade
*
Youth's School
*
Armadillo Technical Institute
Ashland High School
Ashland Middle School
Butte Falls Secondary
Connections Alternative School
Crater High School
Crater Renaissance Academy
Crater School of Business Innovation and Science
Eagle Point High School
Eagle Point Middle School
Hanby Middle School
Hedrick Middle School
Home-schooled
Lake Creek Learning Center
Logos Public Charter School
Madrone Trail Public Charter School
McLoughlin Middle School
Medford Opportunity High School
North Medford High School
Other (not listed)
Phoenix High School
Prospect Charter School
Rivers Edge Academy Charter School
Rogue Community College
Rogue River High School
Rogue River Middle School
Scenic Middle School
Shady Cove School
Siskiyou School, Ashland
South Medford High School
Southern Oregon University
Talent Middle School
The Valley School (Medford)
Upper Rogue Center for Educational Opportunities (URCEO)
White Mountain Middle School
Not Currently Enrolled in School
Youth's Phone
May RVM staff responsible for the YLAB program send text updates & reminders to this youth, at this number?
All RVM Staff are extensively background-checked and trained, and all communication with youth in our programs is subject to over-sight by RVM's Executive Team.
Yes
No
Youth's Email
Youth's Employment Status
*
Under age 14 (Ineligible to work)
Employed Part-time
Employed Full-time
Paid Internship
Unpaid Internship
Not Employed
Unknown / Prefer not to Share
Youth Personal Information
Please, have youth complete this section, if possible.
Did the youth agree to join the Youth Leadership Advisory Board (YLAB)?
*
Yes
No
Why does the youth want to join YLAB?
What are some values and beliefs that are important to the youth?
List any skills, hobbies, interests, languages, and anything else you would like us to know about the youth!
How did you hear about Rogue Valley Mentoring?
*
Friend / Word of Mouth
Search Engine (Google, Bing, etc.)
Referred by Another Organization
FaceBook
Instagram
Other
Parent or Guardian #1 Information
Parent or Guardian #1 Full Name
*
First
Last
Parent or Guardian #1 Relationship to Youth
*
Parent or Guardian #1 Full Address
*
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent or Guardian #1 Phone
*
May RVM staff responsible for the YLAB program send text updates & reminders to the parent/guardian for this youth, at this number?
*
Yes
No
Parent or Guardian #1 Email
*
Do you want to enter information for a 2nd Parent or Guardian?
*
You will have an opportunity to enter an Emergency Contact.
Yes
No
Parent or Guardian #2 Information
Parent or Guardian #2 Full Name
First
Last
Parent or Guardian #2 Relationship to Youth
Parent or Guardian #2 Full Address
Street Address
Address Line 2
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Parent or Guardian #2 Phone
Parent or Guardian #2 Email
Emergency Contact
Emergency Contact Full Name
*
First
Last
Emergency Contact Relationship to Youth
*
Emergency Contact Phone
*
Emergency Contact Email
Agreements and Signature
I give my permission, without compensation or time limitation, for Rogue Valley Mentoring (RVM) to use images that include me and my minor child, taken during RVM programs, in promotional or educational materials, both in print or on the Internet.
*
I agree
I have read and understand the below statement and I am willing to take part in Rogue Valley Mentoring evaluation procedures.
*
Rogue Valley Mentoring relies on an evaluation process to inform the quality and effectiveness of services. I understand that Rogue Valley Mentoring will collect information from me using occasional surveys. I also understand that any information received through evaluation will be kept confidential. Furthermore, I understand that my participation in this program’s evaluation process is completely voluntary and that I can choose not to participate in program evaluation and this will not affect my participation in this program.
I agree
Send registration confirmation email & general communications to this email address:
*
Agreement
*
By checking 'Yes', I agree that all information provided above is correct to the best of my knowledge. This will act as a digital signature confirming this.
Yes
Name
This field is for validation purposes and should be left unchanged.
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About
About our Organization
History
Team & Partners
SO Health-E
Testimonials
Programs & Services
One-to-one Matches
Community Programs
Rising Resilient Summer Camp 2024
Summer Camp – Camp Counselors
Youth Leadership Advisory Board
UNIDOS
School Circles
Refer a Youth
Volunteer
Become a Mentor
Mentor Training Calendar
Contact
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