EBAN Project Registration (BIBB)

Thank you for your interest in our programming. You must reside in Macon-Bibb County and be between ages 13 - 19 to participate in the EBAN Project.

To better serve our communities, GCAPP collects the following demographic information. Your decision to share personal demographic information is entirely voluntary; if you choose not to share there will be no penalty or consequences and you will still have full access to GCAPP’s services and resources.

All information you share is kept confidential to the full extent allowed by law. All data is secured within GCAPP’s database accessible only to the evaluation team and GCAPP staff.

We appreciate your responses.

Program

How did you learn about this program?

If you selected Motivating Youth Foundation, which program do you participate in?

If you selected Not Listed, please write the name of the organization you participate in.

First Name

Last Name

Contact Information

Phone

Demographic Information

Race / Ethnicity

Not Listed Race / Ethnicity

Are you Hispanic, Latino or Latinx?

Gender

Not Listed Gender

Personal Pronoun

Not Listed Pronoun

Not Listed Orientation

County of Residence

Birthday (mm/dd/yyyy)

Please read this entire message and select 'YES' to indicate that you understand the above and agree to participate in this program.

The Georgia Campaign for Adolescent Power & Potential (GCAPP) is working with organizations in Macon-Bibb County Georgia to implement the EBAN Project to empower young people to be safe and make healthy life choices. Through evidence-based mentoring and youth development programming, GCAPP and its partners seek to reduce teen pregnancy and STD rates while promoting responsible adolescence.

Confidentiality: No information collected about your child will be shared in materials or reports produced about the program. We will keep all personal information about your child confidential. There is no link between your child's name and the comments made during any program discussions. Please note that all GCAPP and EBAN Project staff are mandated reporters and must report any information received from or about a youth that is of a concerning nature.

Risks: Your child's participation in this program poses few, if any, risks to them. Your child's participation is entirely voluntary. Your child may end participation at any time and for any reason. If your child withdraws from the program, it will have no impact on any services.

Time Commitment: Your child is invited to participate in a health education program focused on building optimal adolescent health. During the program, your child will spend a few hours each week participating in virtual class about health behaviors, relationships, and lifestyles. Your child's participation will include engaging in online (and, when safe, in-person) mentoring activities. To ensure that we collect information in the same way from everyone, attendance information will be collected before your child leaves each session. In addition, to ensure that all participants receive quality instruction, certain class sessions may be observed for quality in delivery of the program. At the end of the program, your child may be invited to participate in a discussion with other youth participants to reflect on their experience with the program.

Allergies: Please share any food or materials allergies that your child has. GCAPP is not responsible for any allergic reactions to food or materials ingested or handled during while participating (when safe, in-person) in this program.

Benefits: Your child may receive a token of appreciation for time spent participating.

Contact information: If you or your child has any concerns about participation in this program, please contact Mr. D’Lareg Lee, Program Manager, at 404-475-6048

Please select 'YES' to indicate that you understand the above and agree that your child can participate in this program.

Contact Information