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MACON, GA STS Youth Mental Wellness COPE Clinic Registration and Waiver
In partnership with River Edge Behavioral Health, Silence the Shame is pleased to invite you to the Youth Mental Wellness Community Outreach & Practice Effort (COPE) Clinic to engage in authentic and uncensored conversations around mental health and wellness. The COPE Clinic is open to teens (ages 13-19) and their caregivers who live in the Macon-Bibb County surrounding area. Teen participants will connect and discuss with a panel of their peers on managing daily stress and prioritizing wellness. In addition, participants will engage in Expression Stations, where they will have the opportunity to gain professional and personal skills-based experiences such as content creation, podcasting, and practicing wellness strategies. Some of the wellness strategies consist of journaling, positive self-talk, yoga and goal setting.

We also invite parents/caregivers/mentors to participant in our Parent Café session where adult participants will be provided a safe space to manage their wellness, learn how to be trusted adults, and promote healthy development for their youth with a licensed behavioral health professionals. (Please indicate on registration form if the caregiver is going to stay for session).

During this clinic, teens and caregivers will:
  1. Learn to recognize signs / symptoms of crisis and suicide from professionals & people with lived experience.
  2. Access resources that support physical & behavioral health, economic stability and community engagement. 
  3. Practice skills and techniques to promote suicide prevention and healthy living. 
Date & Time: Saturday, September 16, 2023 from 10:30 am to 2:30 pm; Doors open and check-in begins at 9:30 AM.
Location:  River Edge Behavioral Health, 175 Emery Hwy, Macon, GA 31217.  Parking is open and free to participants.

A few things to note:
  • This is an in-person event offered at no cost to participants; lunch will be provided at the event. We may engage in physical activities so dress comfortably. 
  • Youth participants will receive a $25 amazon gift card for their full participation in the COPE Clinic. They will also have a chance to win a refurbished Microsoft SurfacePro Laptop and more. 
  • This summit is open to teens ages 13-19 year in Macon-Bibb County and surrounding areas. Parents, caregivers and child-supporting adults are invited to join.
  • This event will be recorded and shared to more communities. Therefore by registering, you will be requested to give consent for content to be utilized. If you choose not to be recorded then we encourage you to steer clear of recording content. 
*Below we ask for personal demographic information. Why do we ask this? This information is utilized to ensure that our programming aligns with the diversity and unique cultural perspectives of the communities that we serve. This organization does not discriminate on the basis of race, religion, gender identity, age, national origin, sexual orientation, or disability in any of its activities or operations. These responses are optional.

You must be 18 years old to register, please complete the form below with a valid email address for all communication. If you are a caregiver answer for the teen and if you are a young adult answer from your perspective.

This event is sponsored by Healthcare Georgia Foundation.
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Email *
Young Person Name (First and Last) *
Young Person's Email *
Young Person's Age (This event is designed for youth ages 13-19) *
What county does your teen/you reside in? *
If selected other, please list county below:
What race best describes the teen / you? *
Required
Are you of Hispanic/Latino origin? (A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race.) 
 *
To which gender does the youth / you most identify?
 *
Does the teen / you identify as a member of the LGBTQA+ Community? *
Do you or your teen have any dietary restrictions? *
I.e. Vegetarian, Vegan, Dairy Allergy, etc
If yes, please explain below:
Do you or your teen have any medical conditions or allergies that we should be aware of?
 *
If yes, please explain below:
Do you or  your teen require any special accommodations?
 *
If yes, please explain below:
Parent/Guardian/Young Adult Name
 *
Parent/Guardian/Young Adult  Email
 *
Parent/Guardian/Young Adult Phone Number
 *
Does Parent/Guardian plan on staying for the Summit / Parent Cafe?
 *
Media Release / Liability Waiver

Media Release

I, (Name Below), grant permission to Silence the Shame, Inc. employees, volunteers, and partners, hereinafter known as the “Media” to use my image (photographs and/or video) for use in Media publications including: Videos, Email Blasts, Recruiting Brochures, Newsletters, Magazines, General Publications, Website and/or Affiliates.

I hereby waive any right to inspect or approve the finished photographs or electronic matter that may be used in conjunction with them now or in the future, whether that use is known to me or unknown, and I waive any right to royalties or other compensation arising from or related to the use of the image.

Please select below to which is applicable to your present situation:

- I am 18 years of age or older and I am competent to contract in my own name. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

- I am the parent or legal guardian of the below named child. I have read this release before signing below, and I fully understand the contents, meaning and impact of this release. I understand that I am free to address any specific questions regarding this release by submitting those questions in writing prior to signing, and I agree that my failure to do so will be interpreted as a free and knowledgeable acceptance of the terms of this release.

As representation for an adult participant (the “Myself”) or as the legal guardian of the underage participant (the "Minor"), and on behalf of Myself and/or of the Minor, I hereby give permission for Myself or the Minor to participate in Silence the Shame, Inc. (the “STS”) program activities, including but not limited to the use of the equipment and the facilities of Silence the Shame's Youth Mental Wellness COPE Clinic to be held at River Edge, 175 Emery Hwy, Macon, GA 31217.

Liability Waiver

In consideration of Silence the Shame allowing Myself and/or the Minor to participate in the Activities, I hereby release and hold harmless , Silence The Shame, Inc., and their subsidiary and affiliated companies, and all of their respective directors, officers, shareholders, employees, agents, sponsors, successors and assigns (the “Silence the Shame Parties”), from any and all rights, claims, demands, losses, damages, expenses, costs and actions(including reasonable attorneys' fees) which I and/or, the Minor, and our heirs, executors, representatives or assigns may have in connection with Myself and/or the Minor's participation in the Activities, including without limitation, any bodily injuries, death, personal injuries, sickness or disease (including communicable disease), or property damage that Myself or the Minor may incur or which may arise or result from Myself and/or the Minor’s participation in the Activities. I acknowledge that Myself and/or the Minor’s participation in the Activities shall be subject to the rules and regulations which Silence the Shame or Silence the Shame Parties may require and that I shall be obliged to pay for any damage that Myself and/or the Minor may cause in connection with Myself and/or the Minor’s participation in the Activities.

Please select all applicable options below: *
Required

Legal Adult or Parent/Guardian consent (By typing your name below you consent to media and waive liability). 

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