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LiFT Workshop Registration

Saturday, June 6th, 2026

10:00 am-4:00 pm

Mitchell County High School

1000 Newton Road

Camilla, GA 31730

*IMPORTANT NOTE: Please complete 1 Registration Form per Family*

The Demographic Questions are for the person completing the form.

For Salesforce
This section must be entered for Salesforce connectors.
These fields must be hidden, participants will not see this section.
Use the Default Value field under "Options" to enter the value for all participants

Program or Project (enter the program or project the form is associated with)

Program Cohort (enter exact cohort name from Salesforce)

Owner (Enter the name of the staff member responsible for the form)

Form Name (enter the exact form name in Form Assembly)

Thank you for registering for GCAPP's LiFT workshop!

LiFT is a 6 hour workshop for young people (ages 13-19) and their parents/caregivers/trusted adults to learn healthy communication skills. This workshops is made for families only, including youth and their trusted adult. Registering for this workshop means that at least 1 youth and 1 adult will be attending the workshop.

Please complete the registration form below so that we know how many people plan to attend our workshop.

To better service our communities, GCAPP collects the following demographic information. Your decision to share personal 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.

By providing your contact information, you consent to GCAPP contacting you with information about programs, resources, events, and awareness initiatives related to our mission. Your information, including your email address, may also be used to support outreach and engagement efforts, such as connecting with you on social media. You may opt out of these communications at any time.

Your responses are confidential and will be kept private to the fullest extent allowed by law. Any personal information you provide, including your name and email address, will be securely stored and used only by GCAPP for purposes related to this survey and follow-up communication. Individual responses will not be shared publicly.

Registrant (Person Completing Form)

First Name	Last Name
Email	Phone

Youth/Young Adult Participant Information

Are you a GCAPP Youth Advisory Council (YAC) Member?

YesNo

Demographic Information of Person Completing Form

Race / Ethnicity

Sex assigned at birth

County of Residence

Zip Code

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How many other people will be attending the workshop?
(Please select all that apply)

Note: You must register at least 1 youth AND 1 adult to attend this workshop

Number of adults

Number of youth

Enter the First and Last Names of Other Adults

Other Adult 1

First Name

Last Name

Other Adult 2

First Name

Last Name

Other Adult 3

First Name

Last Name

Other Adult 4

First Name

Last Name

Enter the First and Last Names of Other Youth

Other Youth 1

First Name

Last Name

Other Youth 2

First Name

Last Name

Other Youth 3

First Name

Last Name

Other Youth 4

First Name

Last Name

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Dietary Restrictions

Do you, or anybody that is attending the workshop with you, have any food allergies or dietary restrictions?

YesNo

Please list all food allergies or dietary restrictions below:

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Your Consent

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

We invite your child to participate in the LiFT Workshop. This program empowers young people to be safe and make healthy life choices. We also seek to reduce teen pregnancy and STI 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. Also, our staff are mandated reporters and must report any information 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 will spend a total of six (6) hours in the LiFT workshop. Attendance information will be collected and certain class sessions may be observed for quality. Your child may be invited to discuss their experience in the program along with other youth.

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 will 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 Shay Ross, Program Manager, at Quashavis@gcapp.org.

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

This workshop is for youth (ages 13-19) and their trusted adult. Registering for this workshop means that at least 1 youth and 1 adult will be attending the workshop. Please select confirm that you acknowledge and understand the purpose this workshop below.

I acknowledge and understand the purpose of this workshop