Take 5 Registration

The Teen Awareness Group of Hudson Headwaters will be presenting the FREE five-hour health education program for teen's ages 12 to 18 focusing on risk reduction and sexual health and wellness. Each workshop provides facts and information to help teens delay sexual activity; prevent unplanned pregnancy and STD/HIV infections.

The program includes lunch, snacks, educational information, and fun! Advanced registration and parental permission is required. Additional information can be found at www.teenawareness.net/events or by phone to 518-761-0300 ext. 31119!

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* 1. Which Take 5 Teen Health Workshop are you registering for?

Thursday August 4 at the Village Green, Community Room
One Delaware Avenue, Glens Falls

Thursday August 11 at Whitehall Recreation Center
28 Williams Street, Whitehall

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* 2. Please provide us with the follow details for the participant:

Name:

Address:

Phone Number:

Email:

Age:

Grade Level:

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* 3. Do you have any known food or latex allergies?

Yes

If you have answered yes, please list them.

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* 4. Please pick one of the following sandwich choices for lunch:

Turkey

Ham

Veggie

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* 5. Do you give permission for your child to be included in group photos for future promotion of the group/activities?

I do give permission for my child to be included in group photos.

I do not give permission for my child to be included in group photos.

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* 6. I give permission for my child to participate in the Take 5 Teen Health Workshop. I understand that it contains medically accurate information regarding reproductive & sexual health. Participation is voluntary, by virtually signing I give my permission for my teen to participate. (Parent/Guardian's signature)

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* 7. At the completion of the program, each participates has the choice of an iTunes, Regal Cinemas, or Bow Tie Gift Card. Please select one gift card (while supplies last).

iTunes Gift Card

Regal Cinemas Gift Card

Bow Tie Gift Card

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* 8. If you have any further questions, please contact the Teen Awareness of Hudson Headwaters at (518) 761-0300 ext. 31119 or leave us a comment below!