DOVES Network Youth Ambassador and/or Peer Support Group Interest Form
Please take a moment to complete the below inquiry form. A member of our team will contact you within 24-48 hours. Thank you!
* Required
Date of Contact
MM
/
DD
/
YYYY
Parent or Teen Submitting?
*
Parent
Teen
Teen First Name, Last Name
*
Your answer
Has the teen been exposed to and/or experienced domestic violence?
*
Yes
No
Program of Interest
*
DOVES Network Peer Support Group
DOVES Network Youth Ambassador
Both
Required
Teen Contact Email
*
Your answer
Teen Contact Number
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Zip Code
*
Your answer
School District
Your answer
Teen Preferred Method of Contact
*
Email
Text
Phone
Zoom
Does the youth have technology to access webinar meetings?
*
Yes
No
Possible
Is the teen able to attend peer sessions Wednesday's @ 4pm (Arizona) / 7pm (EST)?
*
Yes
No
Is the teen able to attend peer sessions Saturday's @ 10am (Arizona) / 1pm (EST)?
*
Yes
No
If 'no' was selected to any of the days and times above, please list the availability that is preferred. *Note - this does not confirm we will be able to accommodate, but will be taken into consideration.*
Your answer
Parent / Guardian Name
Your answer
Parent/Guardian Email Address
*
Your answer
Parent/Guardian Phone Number
*
Your answer
Parent Preferred Method of Contact
*
Email
Text
Phone
Zoom
What interests you about signing up for either DOVES Network Peer Circles?
*
Your answer
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