Parent/Guardian Email *

Parent/Guardian First Name *

Parent/Guardian Last Name *

Parent/Guardian Phone *

Parent/Guardian Language Preference

Yes, I would like to receive emails and texts about how COPE helps youth, including parent education and counseling options. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Youth First Name *

Youth Last Name *

Youth Phone (if available)

Youth Email (if available)

Youth Gender *

Youth Date of Birth *

Youth Race/Ethnicity *

Youth Language Preference *

‎ Opt-in

Yes, I would like to receive emails and texts about how COPE helps youth. Message & data rates may apply. You can reply STOP to unsubscribe at any time.

Address *

Street Address

City *

State *

Country *

Postal code *

For Mentees in the Across Ages Program, I understand that:

I will participate in a community project.
Photos and videos will be taken throughout the program. I grant my consent and full rights to COPE Family Support to use these photos and videos in all their materials.
I will participate in this program for 6 months.
I will be paired with an adult mentor and will meet 1-2 times a month.
I must have my parent/guardian’s consent to participate in this program.

I accept these terms and conditions:*

Signature of Youth

Clear

As a parent/guardian of a Mentee in the Across Ages Program, I understand that:

My child will be paired with an adult mentor (age 55+) for the next 6 months.
Photos and videos will be taken throughout the program. I grant my consent and full rights to COPE Family Support to use these photos and videos in all their materials.
My child will be asked to complete pre and post assessment questionnaires related to mental health, well being, and program facilitation to meet requirements for COPE Family Support’s program operations and funding.
I give consent for my child to participate in the Across Ages Youth Mentorship Program at COPE Family Support.
Because the program where my child is being served receives funds under local and state entities, COPE is required to report and collect participant-level data . Program staff will share appropriate, required data, held in a secure database, with appropriate funding entities which will be compiled into aggregate data across the state and locally that will be examined and used for future initiatives.

I accept these terms and conditions:*

Signature of Parent/Guardian

Clear