Talk About It ACC 17 Days Student Tracker

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Thank you for your interest in our Talk About It ACC Seventeen Days Workshop! This workshop goes over topics of contraception, STI/HIV prevention, and decision making in our relationships.

This program will be completed through an interactive website. Participants should expect to spend about 1 hour to an 1 - 1.5 hours on this workshop. Upon completion of the program, participants will receive a $25 gift card to compensate them for their time!

Please answer the following demographic questions to the best of your ability. These questions help us understand who our program serves.

Thank you for taking the time to complete this form. The information you provide will stay private and confidential. A Health Educator will reach out to you shortly with workshop information!

First Name *

Last Name *

Pronouns

Date of Birth *

YYYY

Age *

Phone Number *

ZIP code

(Please enter the 5-digit code of your primary residence. If unsure, you can enter the zip code of the setting/campus where you're participating.)

Email Address *

Which ACC campus do you attend? *

Highland

Riverside

Other:

Have you completed a BAE-B-SAFE or Talk About It ACC program before? *

Yes

PARTICIPANTS UNDER THE AGE OF 18 YEARS OLD MUST COMPLETE A PARENT CONSENT FORM. TEXT A PICTURE OF THE SIGNED AND COMPLETED CONSENT FORM TO 512-827-9032

Talk About It ACC PARENT CONSENT FORM

For the next 4 questions, please answer yes or no if the following applies to your current situation:

Are you currently pregnant and/or parenting? *

Yes

Are you currently in the juvenile justice system? *

Yes

Have you recently run away and/or are homeless? *

Yes

Are you currently in the foster care system? *

Yes

Which upcoming Seventeen Days Workshop will you be joining us for? There are virtual and in-person options available! *

I would like to complete 17 Days this week from home :)

I would like to be informed when there will be a 17 Days option in-person on campus

Questions/Comments/Concerns:

Thank you for completing this form! A Health Educator will be contacting you soon with further information about the Workshop! :-)

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