Youth Enrichment Program (Y.E.P) Intake Form
The Youth Enrichment Program (Y.E.P) is a Free co-ed program that focuses on: 
  • Job-Readiness
  • Health & Wellness
  • Academic Achievement
  • Civic Responsibility
  • Financial Literacy
  • Restorative Circles
  • Anti-Bullying & Harassment (HIB)
  • Self/Community Development
Y.E.P. is an extension of The Still Here Village Youth Programs. Still Here (Stillh3r3 Inc.) has partnered with The HUB to serve at-risk youth (13-17 y/o) who reside in Trenton, NJ. 
Every Wednesday May 14 – Aug 6, 2025, 5-7 PM 
This form must be completed by a parent or Guardian. If a question does not apply to you, simply enter “N/A.”
The completion of this form does not guarantee enrollment
A Still Here team member will contact you to complete the admissions process
www.stillh3r3.com 609-608-8616
Email *
Participant's Full Name *
Participant's Gender *
Participant's Date of Birth *
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Grade Level *
  School Name   *
Home Address, please include city, state & zip code *
Parent/Guardian Full Name *
Parent/Guardian Phone Number *
Parent/Guardian Email Address *
Relationship to Participant   *
Parent/Guardian preferred method of contact *
 Participant's T-shirt Size   *
 #1 Emergency Contact Name / Relationship / Phone #   *
#2 Emergency Contact Name / Relationship / Phone #   *
Does your child have any medical conditions or allergies?   *
  If yes, please specify.   *
Is your child currently taking any medications?   *
If yes, please list   *
Does your child have any dietary restrictions?   *
If yes, please describe   *
Are there any accommodations or support your child requires to participate fully in the program? If yes, please detail *
How did you hear about Still Here's Youth Enrichment Program? *
I understand that Still Here's Youth Enrichment Program will cover topics, which may include discussions on mature subjects, including accountability, intense or controversial subjects, and the use of profanity. I consent to my child's participation in these discussions.   *
I understand that Youth Enrichment Program participants may engage with other participants who may be justice impacted. *
I give permission for my child to participate in all activities organized for participants of the Youth Enrichment Program.  *

I, the undersigned, am the parent or legal guardian of the minor participant named above. I hereby grant Still Here (Stillh3r3 Inc), its agents, partners, employees, and authorized representatives the irrevocable and unrestricted right to:

Capture photographs and video recordings of my child during program activities.

Use, reproduce, and publish these materials for any lawful purpose, including but not limited to promotional materials, publications, websites, social media platforms, and other media outlets.

I release and hold harmless Still Here (Stillh3r3 Inc), its agents, partners, employees, and authorized representatives from any claims, demands, and liabilities arising out of or in connection with the use of these materials.  

 *
I understand that my child's participation in the Youth Enrichment Program is entirely voluntary. I acknowledge that I have the right to withdraw my child from the program at any time without penalty or loss of benefits to which my child is otherwise entitled. *
I understand that (2) no call - no shows may forfeit my child's enrollment in the program. Allowing youth on the waitlist to participate in programming.
Please let us know when your child will not be attending. 609-608-8616 or stillhra@gmail.com  
 *
I understand that sensitive topics will be discussed, and I will ensure that my child acknowledges the importance of maintaining confidentiality to create a safe space for all participants.   *
By submitting this form, I release Still Here (Stillh3r3 Inc.) its team members, and partners from liability for any injuries or incidents that may occur during program participation, except in cases of gross negligence or willful misconduct   *
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