Utterback Middle School

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Utterback MS TOP Club

• Name
  First Last
• Participant Date of Birth
  Date Format: MM slash DD slash YYYY
• Grade
  6789101112
• Gender
  MaleFemale
• Program Location*
  Utterback Middle School
• Select Teacher
  • Alvarez
  • Sutherland
• Address*
  Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code
• Parent/Legal Guardian Name*
  First Last
• Email*
• Phone*
• Teen Outreach Program virtual delivery. I understand the program aims to address and prevent teen pregnancy and includes discussions on healthy relationship, goal setting, and sexual health related topics such as sexually transmitted diseases and contraception.*
  YES, I allow my child to participate in virtual learningNO, I do not allow my child to participate in virtual learning
• I also understand an on-line confidential pre and post survey will also be administered to my child and data collected will be used for the purpose of program improvement, assessing whether critical program components or activities were implemented and whether they had an impact upon determinants, important behaviors and overall health goals.*
  YES, I allow my child to participate in the on-line program evaluationNO, I do not allow my child to participate in the on-line program evaluation
• Arizona Youth Partnership (AzYP) has permission to use my child's first name and any photographs, video tapes, slides, etc. of me and/or my children in stories about AzYP for the media, funding sources, and AzYP materials.*
  YESNOThird Choice
• Parent initials here*
• Date*
  Date Format: MM slash DD slash YYYY