YES!

Is the person being referred a Baltimore City resident?(Required)

Thank you for your interest in this program. Unfortunately, we are only able to service residents who live in Baltimore City. In the event, we open services to other jurisdictions and you would like to be notified, please provide your contact information below. Stay Stafe!

To learn more about other BCTT services, provide your email address:(Required)

Who is making this referral?(Required)

REFERRAL SOURCE

Organization Name:(Required)

Contact Persons Name:(Required)

First Last

Contact Persons Email:(Required)

Contact Person's Phone:(Required)

PARTICIPANT INFORMATION

Name:(Required)

First Last

Date of Birth:(Required)

Current Age:(Required)

This program is for individuals 12-24.

Street Address:(Required)

Zip Code:(Required)

Is the youth school age?(Required)

Highest Level of Education:(Required)

PARENT/GUARDIAN INFORMATION

Name:(Required)

First Last

Phone:(Required)

Email:(Required)

GROUP TOPICS

On a scale of 1 (Not Comfortable/Knowledgeable) – 5 (Comfortable/Knowledgeable), identify your level of comfort with discussing the following topics:

Hazards of smoking/chewing tobacco:(Required)

Hazard of using drugs and alcohol:(Required)

Someone I can talk to when I need help:(Required)

Setting Goals:(Required)

Talking about sex and relationships:(Required)

Violence in the community:(Required)

CONSENT

Liability Waiver:(Required)

I, hereby agree to release and hold harmless from any liability, BCTT including its paid and volunteer staff executors, administrators, and other agents representing BCTT. This waiver specifically relates to personal injury which may occur while participating in any programs or activity of any kind conducted, approved, organized, or sponsored by BCTT or its representatives. Further, the consideration for this waiver is the right, privilege, and opportunity for myself/my child to participate in the programs and activities conducted, approved, organized, or sponsored by BCTT.

Photo/Media Consent:(Required)

If I choose to consent and authorize BCTT to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form). I authorize BCTT to copyright the materials, and I authorize BCTT to use, reuse, copy, publish, display, exhibit, reproduce, license to a third party, and distribute the materials in any educational or promotional materials or other forms of media, which may include, but are not limited to university publications, catalogs, articles, magazines, recruiting brochures, websites or publications, electronic or otherwise, without notifying me. I agree with these items to be used up to 99 years after the initial date of use. I agree that I am participating on a voluntary basis and I will not receive any payment from BCTT for signing this release or as a result of any publication of the materials. If I choose to be photographed or recorded, I do not consent or authorize BCTT to take photographs or motion pictures of myself (and/or my child); or to produce videotapes, audiotapes, closed-circuit television programs, webcasts, or other types of media productions that capture myself (and/or my child’s), voice, and/or image (any of the foregoing types of media are called the “Materials” in this Consent and Release form).

Parent/Guardian or Participant Signature:(Required)

RELEASE OF INFORMATION

School Name:(Required)

School Address:

Street Address ZIP Code

Building Communities Today for Tomorrow is requesting

the following documents:(Required)

Current Report Card

Current Attendance Record

for the following youth:

Student Name:(Required)

First Last

Date of Birth:(Required)

Address:(Required)

Street Address Address Line 2 City State ZIP Code

As the Parent/Guardian,

Parent/Guardian Name:(Required)

First Last

Phone:(Required)

I voluntarily give my consent to authorize BCTT to request the identified documents from now until JUNE 30, 2022.

Parent/Guardian Signature:(Required)

Today's :Date(Required)

Dare to Be King/Queen

REFERRAL SOURCE

PARTICIPANT INFORMATION

PARENT/GUARDIAN INFORMATION

GROUP TOPICS

CONSENT

RELEASE OF INFORMATION