Sistas N Bloom Registration Step 1 of 2 50% Youth Name* First Last Nick Name Date* MM slash DD slash YYYY Age*Date of Birth* MM slash DD slash YYYY Gender* Female Male Race* Ethnicity* Current School* Current Grade* Do you have allergies?* YES NO If YES Please Specify* Parent/Guardian #1Name* First Last Relationship to Youth* Address* Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* Phone Number*Phone NumberEmergency Contact* Yes No Parent/Guardian #2Name First Last Relationship to Youth Address Address Line 2 City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email Phone NumberPhone NumberEmergency Contact Yes No Future Life Goals(This information will help us match you for the Sista to Sista Monitoring Experience.) All Program Participants are expected to: Remain with the group at all times. Be respectful to all in attendance. Follow the SIHLE Guidelines as posted in the youth room Attend all SIHLE Sessions to qualify for rewards. Parents will be interviewed by BLOOM UPSTATE INC. facilitators before being accepted into the program. Consent* My parent and I understand the guidelines above and realize, if violated, actions deemed necessary by the staff will be taken which may include parental contact. I want to be involved with the Bloom Upstate program. I understand the information in this application will remain confidential and be used only by Bloom Upstate facilitators. I understand this is a voluntary program and that Bloom Upstate events must be a top priority for me during the program. I have permission from my parent(s)/guardian(s) to participate in the Bloom Upstate program.Initial* “SIHLE” Parental/Guardian Consent Form Your child has been invited to participate in a young women’s SISTAS INFORMING, HEALING, LIVING & EMPOWERING WORKSHOP, “SIHLE,” sponsored by BLOOM UPSTATE INC. SIHLE is a CDC Evidence Based Intervention, peer-led, group-level, social-skills training intervention designed to reduce sexual risk behaviors among African American female teenagers who are at high risk of HIV. In addition to HIV prevention, the program addresses relationships, dating, and sexual health within the specific context of the female African American teenage experience. The program draws upon both cultural and gender pride to give participants the skills and motivations to avoid HIV and other STDs. The program is culturally and gender specific for African American adolescent young woman at risk for negative sexual health outcomes. SIHLE workshop gives young women of color an excellent opportunity to practice communication skills in discussions and activities focused on issues commonly faced during adolescence. The purpose of this workshop is to build a community of self-confident, well-informed young women to serve as a knowledge base and support system for their peers. We know it isn’t easy being a girl and will provide young women with information and resources that will help them successfully navigate their teenage years and beyond. Your child’s participation will truly enhance this experience. We ask that you provide your written consent allowing her to attend and be photographed/video recorded. Feel free to contact the Director, Andrea Johnson, at 864- 497-6048 or andrea@bloomupstate.org if you have any questions or concerns. Thank you in advance for your support. Please complete the bottom half of this form.Name* First Signature*Date* MM slash DD slash YYYY “GIVE” or “DO NOT GIVE”* Give Do Not Give Permission of a child to appear in photographs/video recordings taken at “SIHLE”. These photographs/video recordings may be used on BLOOM UPSTATE’S website, social media pages, promotional materials, and/or in the press.Phone Number*Email* NameThis field is for validation purposes and should be left unchanged. Δ
