Youth Self Referral Application
The Upopolis team will be hosting biweekly virtual meet-up for youth living with specific medical diagnoses and conditions,  the youth of adult patients, and youth navigating grief who re interested in joining or getting more information about the Upopolis online community and programing. You can also disclose your diagnosis or situation to be invited to specific programming . One of the Upopolis child life specialists will reach out to you via email with more details (date, time, login links, and a note about what to expect).  In this application, please use an email that you (the youth) will check regularly. All youth joining Upopolis must be verified by a member of the Upopolis team or referred by a professional before joining the Upopolis online community- it  keeps our user safe. 
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Youth Email (please use email checked by youth) *
Youth First Name: *
Youth Last Name:  *
Preferred Pronouns:
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Date of Birth *
MM
/
DD
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YYYY
Age *
I am interested in (check all that apply) *
Required
Mailing Address, including postal code (if you would like to receive some Upopolis swag or programming supplies e.g journal): *
If you checked that you were also interest virtual support groups and programming for youth diagnoses or situation, please check the box that applies below: *
Emergency Contact First and Last Name: *
Emergency Contact Phone Number: *
How did you hear about Upopolis? *
Where do you live?  *
Required
Please share anything else that might be helpful for us to know before connecting with you during the Common Grounds meet-ups. E.g. accommodations needs like closed captioning.
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