BYA Wellness Center

PARTICIPANT INFORMATION

First Name

Last Name

Date of Birth (MM/DD/YYYY)

Address

Phone

School

Grade

GPA

Major

Career Goal

Gender

FemaleMaleGenderqueer/Non-BinaryDecline to State

Sexual Orientation (optional; choose all that apply):

AsexualBisexualGayStraight (Heterosexual)LesbianPansexualQueerQuestioning or unsuresame-gender lovingan identity not listedprefer not to disclose

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Ethnicity: Hispanic/Latino/a?

YesNo

Race: (Check all that apply)

Black/African AmericanAsianAmerican Indian/Alaskan NativeWhiteNative Hawaiian/Other Pacific IslanderOther or Multiracial

Nationality

Social Media

Parent/Guardian/Caregiver Section

Parent/Caregiver Name

Phone

Mailing Address

Parent/Caregiver Name

Phone

Mailing Address

Please select any of the topics you would like more information about

Please select all that apply

Suicide Prevention Information & ResourcesPositive Coping and Problem Solving SkillsYouth-Led Listening and Info SessionsParent Listening and Info SessionsPositive Ways to Deal with LossOutdoor Activities to Reduce StressYouth-Led Art and Media ProjectsCareer Development Workshops and Job OpportunitiesFinancial Literacy Mindfulness Information & ResourcesDad Support Group Information & ResourcesHarm Reduction Information & ResourcesHealth & Wellness Information & ResourcesGardening Information & ResourcesAny topic you don’t see but want more information and resources on

Please state the topic(s) you want more information and resources on below

How were you referred?

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Social MediaFlyerBYA WebsiteFamily/FriendOther

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For More info about BYA’s Wellness Center, please contact Clif Harrison (Program Coordinator): charrison@byaonline.org

Thank you and have a great day!

Contact Information