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Real Talk Youth Impact Program 840 S. Rancho Drive #4-626 Las Vegas, NV 89106 Phone Number: 702-625-2417 Email:   Pre-­‐Registration  Form     Real Talk is a free charitable program that is designed to hit home with at-risk youth and provide the resources, funding, and support needed for Southern Nevada adolescents to participate in extra-curricular activities of their choice. Please refer to the calendar on the Real Talk website for the date, time, and location of each Change One Meeting. There will be a maximum of 50 participants for each Change One Meeting. Should you not make the first group of 50, your registration will automatically be placed on the following month’s registration calendar. You will receive a confirmation email in response to your request.   Parent/Guardian:_______________________________________________ Parent/Guardian Email: _________________________________________ Address:  ___________________________________________________   Phone  Number:  (_____)  __________________________   Participant  Name:____________________________________________   Age:  ______   Preferred  Change  One  Meeting:  Month:_______________      Year:  _______________        

Eligibility Criteria/Requirements For Youth Participation v All at-­‐risk  youth  ages  8-­‐18   v Attend  all  three  Change  One  meetings   v All  participants  must  attend  all  three  meetings  in  order  to  graduate  from  the   Program  and  to  be  able  to  participate  in  extra-­‐curricular  activities  provided   v It  is  recommended  that  the  participant  complete  the  meetings  sequentially   v If  a  participant  misses  a  meeting,  he/she  will  have  the  opportunity  to  attend  the   following  meeting   v Participant  has  up  to  six  months  to  complete  the  three  required  meetings   v Should  the  participant  fail  to  meet  the  three  meeting  requirement  in  a  six  month   period,  he/she  will  have  to  start  over  and  attend  the  initial  meeting   v Complete  a  before  and  after  survey   v Participate  in  viewing  the  community  support  booths   v Cell  phones  and  all  other  social  media  devices  will  not  be  permitted  inside  the   meetings   v Social  media  devices  are  not  to  be  accessed  during  the  meeting;  you  will  be  asked   to  leave  the  meeting  if  you  do  so   v Address  the  members  of  the  Real  Talk  Youth  Impact  Program  as  “Mr./Mrs./  or   Ms.”   v No  hats   v No  gang  attire   v No  sex  offenders   v All  participants  will  be  required  to  wear  designated  name  tags  at  all  meetings  to   reflect  participant’s  program  phase   v All  participants  will  sign  a  waiver  agreeing  not  use  the  Real  Talk  meeting  as  a   recruiting  ground  for  inappropriate  behavior  

Participant Requirement  For  Change  One  Meetings     v Participants  will  be  provided  a  numbered  name  tag   v Name  tags  will  be  color  coded  to  identify  first,  second,  and  third  time  attendee   v Participants  will  be  given  a  program  brochure  detailing  who  the  speakers  will  be  for   each  Change  One  meeting   v During  the  Change  One  meetings  participants  will  address  the  members  as   “Mr./Mrs./Ms.”       v Upon  completion  of  the  participant’s  third  meeting,  he/she  will  be  provided  a   program  certificate  and  Program  T-­‐shirt   v Each  participant  will  sign  a  waiver  regarding  an  agreement  not  to  use  the  Program  as   a  recruiting  ground  for  inappropriate  behavior     v Each  participant  will  fill  out  an  initial  and  end  of  program  survey                              

Parent/Guardian Requirements     v Complete  registration  form   v Complete  a  before  and  after  survey   v Sign  youth  participation  waiver     v v Attend  the  first  and  third  Change  One  meetings   v Sign  authorization  to  release  confidential  information   v Sign  photo/video  release     v Sign  a  waiver  for  extra-­‐curricular  activity  that  the  participant  has  selected   v Agree   that   members   who   are   currently   on   federal   supervision   shall   not     communicate   or   otherwise   have   contact   with   the   participant   outside   of   the   Program,  in  person  or  through  any  form  of  social  media   v Any   parent/guardian   who   desires   their   participant   to   continue   to   have   contact   with  a  member  who  has  expired  from  supervision  must  sign  a  waiver    


Eligibility Criteria For Youth Rewards and Incentives v Participant must  not  be  in  violation  status   v Maintain  a  2.0  average  in  school   v Be  obedient,  respectful  to  parent/guardian,  speakers,  and  other  participants   v Attend  all  three  mandatory  Change  One  meetings   v Attend  selected  program/extra-­‐curricular  activity  regularly   v Complete  any  court  ordered  community  service   v Attend  school  regularly   v Shall  be  gang-­‐free   v


Shall be  drug-­‐free  

Pre Register Real Talk  
Pre Register Real Talk  

Updated doc 5-28-13