TOP CLUB SIGN UP For more information on the curriculum, click here Utterback MS TOP Club Name First Last Participant Date of Birth MM slash DD slash YYYY Grade6789101112GenderMaleFemaleProgram Location*Utterback Middle SchoolSelect 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 learningI 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 evaluationArizona 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 ChoiceParent initials here* Date* MM slash DD slash YYYY
