Project COURAGE Family Registration

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

The Project COURAGE program includes an online course, to be completed by student AND parent, and a two hour in person class hosted at notMYkid's campus. An optional hour of individual family navigation is available.

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, there will be complete coverage of the $250 cost of this program. 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?

YesNo

I give notMYkid staff permission to verify my child’s attendance with school administration or a referring agency, only when applicable.

YesNo

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

Email for Person from Referring Source (please enter SR for self-referral)

Parent/Guardian Full Name (First M. Last)

Parent's Cell Phone (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 (nicole@notmykid.org)

Relation to child

2nd Parent/Guardian Full Name (optional)

2nd P/G Cell Phone (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.

2nd P/G Email (nicole@notmykid.org)

2nd P/G Relation to child

Child’s Full Name (First M. 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

What happened, or why were you referred to us?

Mailing Address

City

State

Zip Code

County of Residence

Referring Physician (NA if not applicable)

How did you hear about this program?

Contact Information