Youth Rising Program Interest Form

Every young leader needs a safe space to grow. Youth Rising offers mentorship, guidance, and opportunities for teens ages 12–17. Fill out this form so we can keep you informed and support your child’s journey.

Parent/Guardian First Name *

Parent/Guardian Last Name *

Email *

Phone *

Postal Code *

Relationship to Youth *

Preferred Method of Contact *

Phone

Text

Email

Participants Information

Age

Current Grade Level

How did you hear about Youth Rising?

Referral

Social Media

School

Event

Other

Why are you interested in the Youth Rising program?

What skills or areas would you like to see your child/youth develop?

Leadership

Confidence & Self-Esteem

Teamwork & Collaboration

Entrepreneurship & Financial Literacy

Community Service

Other

If you selected other, please specify.

I agree to be contacted with more information about Youth Rising.