Participant (18+) Information
Reset Form
Complete your information below.
This application is for participants 18 years of age and older only.
First Name
(required)
Last Name
(required)
Email
(required)
Elevating Connections Account Password
(required)
Cell Phone
(required)
Birth Date
(required)
Gender
(required)
Select Value
n/a
Male
Female
Genderqueer
Nonbinary
Transgender
Other
Decline to Answer
If Other Gender, how do you identify?
Pronouns
(required)
Select Value
he/him/his
she/her/hers
they/them/theirs
xe/xem/xirs
Decline to Answer
Ethnicity
(required)
Select Value
Asian
Black
Hispanic/Latino
Multi-racial
Native American
White
Prefer not to say
Other
If other ethnicity selected, please specify.
Are you currently part of an open Dependency & Neglect case?
Select Value
Yes
No
Are you currently part of the Foster Youth in Transition Program?
Select Value
Yes
No
Program Interests
Interest: Connecting Events (ages 5-18)
Select Value
Yes
Interest: Community Dinners (ages 15-99)
Select Value
Yes
Interest: Community Events (ages 15-99)
Select Value
Yes
Interest: Camp Connect (ages 8-16)
Select Value
Yes
Interest: Caregiver Support (Caregivers only)
Select Value
Yes
Interest: Arts Workshops
Select Value
Yes
Interest: Poetry Jam
Select Value
Yes
Interest: I am not sure
Select Value
Yes
Authorization for Medical Treatment
I understand that if I am in need of immediate medical attention and there is not time to contact my emergency contact, and if I am unable to consent, I authorize any staff, or volunteers of ELEVATING CONNECTIONS and/or any medical clinic, hospital or emergency facility to administer all medicines, prescription drugs and other medical remedies required for treatment while in attendance and participating at any of the functions or facilities of ELEVATING CONNECTIONS. I further warrant that I have the authority to grant this medical authorization and agree to hold ELEVATING CONNECTIONS and/or medical clinic, hospital or emergency facility harmless by reason of my executing this medical authorization.
I consent to receive medical treatment. Authorization for Medical Treatment
(required)
Select Value
Agree
Disagree
Authorization for Medical Treatment Date
(required)
Emergency Contact
Emergency Contact Name
(required)
Emergency Contact Relationship
(required)
Emergency Contact Email
(required)
Emergency Contact Phone Number
(required)
How did you hear about us?
(required)
Submit
