2017-2018 School Year Survey

Take 5 Teen Health Workshop

The Teen Awareness Group of Hudson Headwaters will be presenting the FREE health education program 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.

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!

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

November 12 from 10:00 am -- 3:30 pm

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

This program is after school or a 2 day program & does not qualify for lunch.

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. *We will call the parent to verify registration within 3 business days.

Parent/Guardian's Signature

Parent/Guardian's Phone Number

7.At the completion of the program, each participant receives a Bow Tie Gift Card.
(Participant must be present for the entire and/or both sessions to qualify for the gift card.)

iTunes

Regal Cinemas

Bow Tie

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