Registration- Youth Resilience Building Program

This form is for adopted, fostered, or kinship youth ages 7-12 (or best developmental fit) who have Never attended the Encompass Adoptees Youth Program before.

Information about registered youth is used by the director to create productive program curriculum, to ensure program is suitable for attending you, and to reference during the Encompass Adoptees Youth Program to support individual youth. All information is kept confidential. For more information on this program please review the Youth Program page.

A Deposit is required due to limited spots and to decrease the number of youth on the waitlist. The deposit amount is $20, and this amount will be taken out of the total ($75) and the remainder ($55) can be paid at the time of drop-off. If for any reason the direct link to pay the deposit does not work, please pay the deposit on our website donation page or this Encompass Donation Link in order to ensure your spot. If you are registering for a waitlist spot- You do Not need to pay the deposit. Payment is due at drop off and cash, check, or credit card payment options are available.

Quick Reminders:

For youth generally 7-12 yrs (or depending on developmental fit)
Group runs from 11-2 pm, One Saturday per month (please arrive 10 min early for drop off)
Location- 122 S Terrace Ave, Columbus
Please have youth wear appropriate clothing for making art, playing outside, and honoring the potential trauma/trauma triggers of other attendees (modest clothing).
Updated registration dates will be posted on the registration form as they are available. Dates that are full will be listed as such on the registration form.
We ask that a packed lunch be provided for each date your child is registered. A microwave is available.
Once registration is full, a waitlist will be created. In the case cancelation is required, we ask that you do so as soon as possible, to allow waitlisted youth to attend.
Mentors are not available to be approached as babysitters or caretakers outside of the hours designated for this program. Encompass Adoptees offers one-on-one mentoring for a fee.

TextParent/Guardian's Name

Child's legal Name/ Preferred name, and pronouns

I understand that my child needs to bring a pack lunch and that everyone eats together half way through the program.

Yes

Please select the dates you. would like to register for.

Nov 23- FULL- please add me to the waitlist

Jan 18

Feb 15

March 29

Deposit

A $20 non-refundable deposit is required for registration per day selected above for each child registered. This amount will be taken out of the total ($75) and the remainder ($55) can be paid at the time of drop off by check, credit card, or cash. Please enter the total deposit amount due for the above selected date/s multiplied by the number of children being registered. *If you are registering for a waitlist spot, please do not pay for it unless you are sent a notification that you have gotten in. Once you submit this form, you will be taken to a secure checkout through Square to pay this amount.

-- For 1st-TIME REGISTRATIONS Only --

If you have Registered before Please Skip the remainder of the questions and hit Submit

Parent/s or Guardian's Information:

Address, and Cell Phone Number Who can we expect to be dropping off and picking up the youth, and who can we talk to if we have questions. This number/s will be used in case we need to reach you, in regards to your child's participation in the program only, unless otherwise specified.

Emergency Contact Name & Number

Who we will can if we can not reach the above person / number

Child's current age and date of birth?

Racial, cultural, and/or gender identity?

How does your child self-identify?

Child's age when they joined your family?

Please tell us about your family composition (siblings or grandparents in the home, etc.)

Is your child in counseling or have a diagnosis?

How is your child doing in school?

Please tell us about your child's social/interpersonal interactions (with peers, younger children, teachers, etc)

What are some strengths and/or interests of your child?

Please list any significant challenges and/or behaviors.

Include challenges such as fear, triggers, trauma response behaviors such as those that may have a sexual or flirtatious nature, sensory needs, etc.

Please list any known current coping skills, calming items, or other known ways to create felt safety for your child.

Please list any know Adoption/Foster related information.

Anything you think may be helpful for us to know as we interact with your child- adoption story, in reunion or not, degree of openness, transracial adoption, previous traumas or abuse (other than relinquishment -voluntary or forced) such as physical or sexual abuse, lack of available food, medical distress/trauma etc...

Have there been any important family events recently?

Please list any moves, new school or teacher, sibling leaving home, sickness or death in the family, etc...

Are there any known topics of concern/ interest relevant to adoption?

Does your child have any known allergies or other health issues?

Does your child require any specific services? (ex: sign language interpretation...)

In the case that specific services are needed we request that you register at least 14 days prior to the event date. We aim to make a space accessible to as many as possible, and some services require that we schedule ahead.

Who, or what agency, referred you- Or how did you hear about Encompass?

Is there anything else you would like us to know?