Youth Therapeutic Art Spring 2023 Application

Youth Therapeutic Art Spring 2023 Application

Starting Saturday, May 13, 2023 at 10:00am-12:00pm

The program will take place every Saturday, May 13, 2023 for four weeks and ending on Saturday, June 3, 2023.

Time: 10:00am-12:00pm

Place: Online-Zoom

Age: Participants must be 9-17 years old.

Admission: free, limited amount of space available

The arts provide children with both verbal and non-verbal means to communicate, express emotions, and relieve tension.

No art experience necessary. Youth will be provided with developmentally appropriate expressive art projects which honor their diverse emotional and physical needs. This is a strengths-based program, meant to assist participants in building their confidence, increasing their self-awareness, developing their coping skills while building meaningful relationships with their peers.

Please email miriam@epilepsynorcal.org for any questions

General Information

First Name

Last Name

Nickname (If applicable)

Birth Date

Age

Cell Phone

Home Phone

Work Phone

Guardian's Name

Parent/Guardian Email

Guardian's Name

Cell Phone

Home Phone

Work Phone

Address

Address Line 1

Address Line 2

City

State/Province

Postal Code

Preferred Phone Number

Emergency Contact Information

Emergency Contact 1

Phone

Relationship to Applicant

Emergency Contact 2

Phone

Relationship to Applicant

Applicant's Physician

Phone

Physician's Address

General Health

Applicant's overall health

Does the applicant have any other medical conditions or physical disabilities?

Allergies?

Support Group

Have you ever participated in a virtual or in-person support group? If so, how was that experience?

What do you hope to get out of this group?

Do you have any experience in the arts? Do you have a favorite art modality?

What kind of expressive arts are you interested in? (For example: writing, drama, music, gentle movement, visual arts)

Is there anything else you'd like us to know about you?

Will you be able to attend all sessions? If not, please indicate the dates or commitment level.

Contact Information