Project REWIND Family Registration

Thank you for your interest in the Project REWIND program, an early action solution for teens and their families. Participants are carefully screened to assess best fit for the program.

The Project REWIND program includes two 2-hour classes. Families are offered 1 hour of individual coaching session for customized support.

Parent involvement is required.

Once you complete and submit the form below, our team will contact you to schedule your class placement.

*Virtual and in person options available.

Thanks to our generous grant-funders and community support, the $250 fee is waived for Arizona families. Participating families for the 2023-2024 academic year will pay $0 in program costs.

Please answer all required questions in the format of the example in parenthesis.

Will your family require Spanish translation services? para español, registra aqui https://www.tfaforms.com/5044037

YesNo

I give notMYkid staff permission to verify my child’s attendance with school administration or a referring agency, only when applicable. This is how your referral source receives updates on your program progress.

YesNoSelf-referral

Name of Person from Referring School/Source to release information (please enter SR for self-referral)

Email address of Person from Referring School/Source (please enter SR for self-referral)

Parent/Guardian Full Name (First, Last)

Parent's Phone Number (ex: 602-858-5939)

By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.

Parent/Guardian Email (ex: Nicole@notmykid.org

Relation to child

2nd Parent/Guardian Full Name (optional)

2nd Parent/Gaurdian Cell Phone

By providing a telephone number and submitting the form you are consenting to be contacted by SMS text message. Message & data rates may apply. Reply STOP to opt out of further messaging.

2nd Parent/Guardian Email

2nd Parent/Guardian Relation to Child

Child’s Full Name (First, Last)

Child's Date of Birth (month/date/year)

Child's Gender

In the case that we cannot reach parent/guardian, do we have consent to reach out to the registered youth participant?

YesNoNot Applicable

Child's Phone Number (enter NA if not applicable, or youth does not have a phone)

Child's Grade

Child's School

Child's School District

Drug of Concern

Mailing Address

City

State

Zip Code

County

Referring Physician (please enter NA if not applicable)

How did you hear about this program?

Contact Information