2019 OFYC Advocacy Convening Participant Application
Legal first name:
Legal last name:
Preferred name for nametag :
Date of Birth (MM/DD/YYYY):
Pronouns (Example: she, he, they):
Cell phone #:
Home phone #:
DHS Case Worker's Name:
DHS Case Worker's Phone #:
ILP Case Manager's Name:
ILP Case Manager's Phone #:
Foster Parent/Guardian's Name:
FP/Guardian's Phone #:
Emergency Contact's Name:
Emergency Contact's Phone #:
Emergency Contact's Relationship to you:
What is the best to follow-up with you? Please check 2 options:
Doctor/Clinic's Phone #:
Medical Card #:
Are you currently taking medications (that you will bring with you to the Conference)?
If yes, please enter the names and dosage (how many you take how often)
If you have any medical needs (allergy, allergy to insect bites, heart condition, diabetes, epilepsy, pregnancy, drug reactions) that we should know about, please describe them here:
If you have any dietary needs please describe them here:
If you have any other needs/accommodations/preferences please describe them here:
Are you parenting?
Yes, I'd like to request childcare
Yes, but I'm not sure if I'll bring them
Yes, but I'm not going to bring them
How do you plan to get to Salem?
I have arranged my own transportation
I need help getting there
How are you getting to the conference?
Have you read the draft "Rule & Expectations" for the conference?
Yes, but please email them to me as a reminder
No, please email them to me
I understand that you need a copy of my medical card:
I will email/mail you a copy
Please contact my case worker for the card
I don't think I have medical coverage
Permission to attend:
My DHS case is closed, I give myself permission to attend
My DHS case is still open, please forward my application to my DHS Case Worker for approval
I'm not sure if my case is open. Can you reach out to me about this?
: Please tell us why you want to come to OFYC’s 2019 Advocacy Convening: Expanding ILP Services. What do you hope to learn? What do you hope to accomplish?
Question #2 (Optional):
The following section is optional. By collecting this data, we hope to better represent all youth in our community so that all voices are heard!
Years in foster care:
Number of foster care placements:
Which types of placements have you live in? (Check all that apply):
I have lived with biological family members
I have lived in group homes
I have lived with foster families
I have lived in a residential facility
I have lived with an adopted family
How do you describe your Race/Ethnicity?
Do any of the following describe your Race/Ethnicity? (Check all that apply):
American Indian or Alaskan Native
Asian / Pacific Islander
Black or African American
Hispanic / Latinx
Middle Eastern / North African
White / Caucasian
Do you identify as part of the LGBTQIA2-S Community?
Please describe (optional):
Do you identify as having a Disability (mental health, ADD, Autism, learning disability, etc.)?
Please describe (optional):
For some participants, conferences like ours can bring up some hard feelings. Self-care is an important tool in your leadership toolkit. Can you please describe a few self-care strategies you could have access to while in Salem? Here are a few examples from other young people:
“1-2-3 breathe in, 1-2-3 breathe out.” Draw, guided meditation apps, or talk to friends or family
. Please let us know how we can support these or other strategies.
Is there any additional information we need to know to better assist you during this conference?
Finally... If we are able to provide you with an OFYC polo (shirt) for this event, whit size and cut (Women's or Unisex) would you prefer?