Blues Program for Teenagers

Register for this event

Event Location

Event Time / Details

Email (we will use this email to send the class Zoom link)*

Number of Teens Attending?*

Teen 1 Name*

First Last

Teen 1 Email*

Teen 1 Phone*

Teen 1 Age*

Please enter a number from 1 to 100.

Teen 1 Grade in School*

Name of School District Teen 1 Attends?*

Teen 1 Gender*

Male
Female

Teen 1 Race/Ethnicity*

Teen 2 Name*

First Last

Teen 2 Email*

Teen 2 Phone*

Teen 2 Age*

Please enter a number from 1 to 200.

Teen 2 Grade in School*

School District Teen 2 Attends?*

Teen 2 Gender

Male
Female

Teen 2 Race/Ethnicity

Please choose the number of children, provide their names and ages.

Address (we will mail your class handouts to this address)*

Street Address Address Line 2 City State ZIP Code

Parent or Guardian Name*

First Last

Parent or Guardian Email*

Parent or Guardian Phone*

Who referred you to COBYS?*

Select Educator Time

Name of person who referred you:

Comments

Consent*

I agree and authorize the information below.

By submitting this registration I authorize and agree to the following:
I authorize COBYS Family Services to provide demographic information (i.e. race, age, etc.) to funding sources and release attendance and/or participation information upon request to the funding source and the participant’s referral source.
I agree and understand COBYS Family Services provides educators. Therefore, I will not ask anyone from COBYS to be called for testimony for any future proceedings. COBYS will acknowledge attendance to classes but no other information.
I understand that COBYS staff are mandated reporters, and are required by law to report to the appropriate agency when there is reasonable cause to suspect child abuse.

Parental Consent*

I agree to this Authorization.

I give my permission for my child to participate in this program, as well as consent to have audio recording of the program if needed for instructional purposes. All program staff are bound by professional ethics of confidentiality.

Blues Program for Teenagers

Registration