Power, Action, Change for Teens Enrollment
PACT is a free, unique, dynamic weekly after school program for teen girls (cis and trans) and gender non-conforming youth ages 12-19. The program meets on Thursdays during the school year from 4:30-6:00.

PACT stands for Power, Action, Change for Teens. We build power by educating ourselves about social justice issues, take action by learning self-defense techniques, work for change by becoming activists and take care of ourselves as teens by practicing self-care.

Snacks are served at the beginning of every class so come early if you can!

PACT will begin on September 27th, 2018. We will meet each Thursday through the end of June, with the exception of any school holidays.

If you have any questions, e-mail or call Izzy: izzy@caeny.org, 718-788-1775

Name *
First and last name
Your answer
Mailing Address (Include apartment number and zip code) *
Your answer
Cell Phone #
Your answer
Home Phone #
Your answer
E-Mail
Your answer
How do you prefer to be contacted?
Date of Birth *
MM
/
DD
/
YYYY
What school do you attend?
Your answer
Parent/Guardian Name #1 *
Your answer
Phone # *
Your answer
E-Mail Address
Your answer
Parent/Guardian Name #2
Your answer
Phone #
Your answer
E-Mail Address
Your answer
What is your gender identity? (optional)
CAE’s funders require us to obtain demographic information in order to better understand who participates in our programs. The information on this form will be confidential. Answering these questions is voluntary.
Your answer
What is your race? (optional)
CAE’s funders require us to obtain demographic information in order to better understand who participates in our programs. The information on this form will be confidential. Answering these questions is voluntary.
Your answer
What is your sexual orientation? (optional)
CAE’s funders require us to obtain demographic information in order to better understand who participates in our programs. The information on this form will be confidential. Answering these questions is voluntary.
Your answer
I am a survivor of… (mark all that apply):
CAE’s funders require us to obtain demographic information in order to better understand who participates in our programs. The information on this form will be confidential. Answering these questions is voluntary.
Have you had previous martial arts or self-defense training?
If YES, what style/where/when?
Your answer
How did you hear about CAE?
Your answer
Do you have any injuries or medical conditions the teachers should know about? *
If YES, please describe below:
Your answer
What are you excited for about PACT? Are there any topics you want to focus on?
Your answer
Thanks! We can't wait to meet you!
Submit
Never submit passwords through Google Forms.
This form was created inside of The Center for Anti-violence Education. Report Abuse - Terms of Service - Additional Terms