Project Unbreakable Summer'24 Registration Form

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Unbreakable Minds Coaching, in partnership with Author, Ayesha Edwards, present "Project Unbreakable: Transforming Lives through I.D.E.A.s". Our dynamic Summer Book Club is for Middle and High School teens to help you embrace your uniqueness, advocate for justice, & take charge of your future. We will collaborate with the author of the novel we are reading to deliver this amazing summer experience to Richmond Youth!

Our Goal: to build participants' fluency and comprehension while focusing on social issues that are of interest to them. This will also provide the awareness, advocacy, agency, and support they need to be change agents in their communities and the world at large. We seek to foster a spirit of volunteerism where each one teaches one and lifts as they all climb the ladder of communal success.

Who: Middle and High School Teens
Dates: July 1 - July 19, Monday - Thursday

Time: 8:30 am - 12:30 pm

Location: St. Thomas Episcopal Church

3602 Hawthorne Ave, Richmond, VA 23222

What's included: All materials + breakfast and lunch

Bonus: Friday Nights are Parent Night

This program is FREE as it is a part of the City of Richmond’s Gun Violence Prevention Initiative. Funding is made possible by the American Recovery Plan Act (ARPA)

Kindly complete this registration form By JUNE 28th so your child will not miss out on this amazing opportunity!

If you have questions, please reach out to Yolanda Hall at 804-495-1282 or coaching@unbreakableminds.org OR Ayesha Edwards at 516-668-6494 or ayesha@reelyrylee.com

Email *

Name of Teen *

Does your teen identify as: *

Male

Female

Address, City, Zip *

Teen's Date of Birth *

Teen's Race (Check all that apply) *

Black

Asian

White

American Indian/Alaskan Native

Hawaiian/Pacific Islander

Hispanic

Other:

Required

School teen will attend for 2024-2025 school year? *

2024-2025 Grade Level *

6th

7th

8th

9th

10th

11th

12th

Teen's school ID # (Richmond Residents ONLY)

Has your teen's school identified him/her as an English Language Learner (Is English their second language)? *

Yes

Parent/Guardian FULL NAME *

Relationship to Teen *

Parent's Phone Number

Preferred language of communication *

Please provide an emergency contact NAME and NUMBER (someone other that parent completing this form) *

Does your teen have food or medical allergies? *

Yes

Required

If yes, please indicate what your teen is allergic to.

Does your teen have any special needs or are there concerns about your teen's social and emotional development you'd like us to know? *

Yes

Required

If yes, please explain

How would you describe your teen's personality? *

Range of Household Income (We ask for this information to get a better understanding of the families we serve and to ensure that resources are equitably distributed across the City of Richmond. Your personal information will not be reported with this number) *

Less than $10,000

$10,000 to $19,000

$20,000 to $29,000

$30,000 to $39,000

$40,000 to $49,000

$50,000 to $59,000

$60,000 to $69,000

$70,000 to $79,000

$80,000 to $89,000

$90,000 to $99,000

$100,000 to $149,000

$150,000 or more

Required

Total number of adults in household (over 18) *

Total number of children in household (18 and under) *

How will your teen be transported to and from Project Unbreakable Summer Camp? (Unbreakable Minds does not provide transportation) *

Teen will be dropped off and picked up by parent/guardian

Teen will be dropped off and picked up by someone else (please select 'other' below and list their name.

Teen will walk to and from camp

Teen will take public transportation to and from camp

Other:

Required

What do you wish for your teen to gain out of Project Unbreakable? *

Anything else you would like for us to know about your teen?

CONSENT: Please read carefully and check each of the following boxes below and then sign below. * *

I give my informed consent and permission for my child to participate Project Unbreakable and its related activities. I give my consent for the program to collect data that informs and improves the program. This includes but is not limited to surveys, focus groups, etc.

I consent to having my child's photo/video taken for promotional purposes across Unbreakable Minds and participating partners' social media platforms.

I understand that violation of Project Unbreakable guidelines may result in dismissal or temporary suspension from programming.

I release Unbreakable Minds and participating partners of all liability of illness (incl. COVID19), injury, death, or other damages to me, my child, family, estate, heirs, or assigns that may result from his/her participation in the program, including but not limited to transportation, and hold harmless any Project Unbreakable volunteer, or other representatives, both collectively and individually, of any injury, physical or emotional, other than where gross negligence has been determined.

Project Unbreakable is funded by the City of Richmond’s Positive Youth Development and Youth Violence Program. The goal of the City of Richmond’s Positive Youth Development and Youth Violence Program is to promote positive youth development and prevent youth violence and help your child reach his or her full potential—socially, emotionally, and academically. To help the City of Richmond achieve that goal, we may need to share certain information about your child with the City of Richmond and NextUp RVA. The City of Richmond has contracted NextUp RVA to distribute funds, provide technical assistance and evaluate programs’ impact on youth outcomes. In turn, they may need to share certain information about your child with us. NextUp RVA is committed to ensuring all youth have a positive, quality learning experience, and sharing this information can help us better serve your child(ren). Additionally, this information will help us understand whether or not this program is having a positive impact on your child’s academic, social, and emotional well-being. By clicking this box, you give your permission to allow RPS to disclose my child’s school records to NextUp RVA.

Other:

Required

Parent/Guardian Name (this will serve as your electronic signature)

Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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