Take 5 Survey

The Teen Awareness Group of Hudson Headwaters will be presenting the FREE health education program. This program is for teen's ages 12-18 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.

Youth will be participating in an anonymous pre/post survey. The goal is to measure the youths' attitudes, thoughts and specific behaviors related to sexual activity. These tools will be returned to the funding source for determining effectiveness of the curriculum. No names will be included in any communication with the funding source.

The program includes lunch, snacks, educational information, and fun! Advanced registration and parental permission is required.

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

July 10 at The Human Services Building from 10:00 am - 3:00 pm
1340 State Route 9, Lake George, NY 12845

2.Please provide us with the following details for the participant:

Name:

Address:

City, State, Zip Code:

Phone Number:

Email:

Age:

Grade Level:

How did you hear about the program?

3.Do you have any known food, latex, or any other allergy we should be aware of?

Yes

If you answered yes, please list them.

4.Pick one of the following sandwich choices for lunch:

Turkey

Ham

Veggie

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

I 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.

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

Parent/Guardian's Phone Number

7.At the completion of the program, each participant receives a $20 gift card. Which option would you like, while supplies last?

iTunes

Regal Cinemas

8.If you have any further questions, please contact the Teen Awareness Group at hrinn@hhhn.org or pmorreale@hhhn.org or leave a comment below.