Youth Application

This information is required for youth without program staff. Our programming is supported by private grants and government contracts that require particular information to continue funding. Data collected below will be kept confidential.

If you have any questions, please contact Kristi Jeffers: kjeffers@exyo.org or (978)927-8600.

Before you begin, please know you will need Emergency Contact and Health Insurance information for the applicant. At any time, you can save the form to be filled out later by clicking “Save and Continue Later” found at the bottom of the form.

If you prefer, you may download a PDF of this form to complete manually and mail to: Express Yourself, 100 Cummings Center, Suite 165-E, Beverly, MA 01915.

"*" indicates required fields

Youth Participant Information

First and Last Name*

Age*

Pronouns*

Gender*

Street Address*

City*

State

Zip*

Has this youth ever participated in Express Yourself before?*

Yes

What year did they begin?*

School*

Grade*

Expected Graduation Year*

Who referred you to Express Yourself?

Name*

Relationship*

Phone*

Email*

Are languages other than English spoken in the youth’s home?*

Yes

If yes, which languages(s)?*

Who will be transporting your child?*

If you give permission for anyone else to transport your child, please list here:

I give permission for my child to leave Express Yourself without adult supervision:*

Yes

Parent/Guardian Information

Youth lives with:*

Both parents/guardians

Parent/guardian 1

Parents/guardian 2

Other

If other, please specify*

Name of Parent/Guardian #1*

Email Address*

Street Address*

City*

State*

Zip*

Best Phone Number to Reach You*

Alternate Phone Number

Name of Parent/Guardian #2

Email Address

Street Address

City

State

Zip

Best Phone Number to Reach You*

Alternate Phone Number

Emergency Contact Information

Name*

Relationship to Youth*

Best Phone Number*

Alternate Phone Number

Should emergency/crisis intervention care be required and I cannot be reached, I authorize staff from Express Yourself to sign for emergency medical attention for my child.*

Yes

In case of emergency, does your child have a therapist, counselor, or case manager that we could contact?*

Yes

If so, please provide name and contact info:*

Please describe any of the following that apply to your child

Special Health Issues

Allergies

Physical or Mental Disabilities

Race/Ethnicity/ of participant:*

Asian/Asian American/of Asian descent

Black/African American/of African descent

Hispanic/Latino/Latina/Latinx/of Latinx or Spanish-speaking descent

Middle Eastern/North African/of North African descent

Native American/American Indian/Alaska Native/Indigenous

Pacific Islander/Native Hawaiian

White/of European descent

Multi-racial or multi-ethnic (2+ races/ethnicities)

Individual(s) decline to state

Household Information

Does the youth participate in a free or reduced lunch program?*

Yes

What is the yearly income range of the youth’s household or family?*

$0 — $24,250

$24,251 — $40,890

$40,891 — $60,000

$60,001 — $80,000

$80,001 — $100,000

Above $100,000

How many people currently live in this household?*

Check all services that youth has been part of:*

Department of Mental Health

Department of Children and Families

Department of Youth Services

Department of Disability Services

Community Based Acute Treatment

Therapeutic Mentoring Program

Individual Youth Services

Family Sibling of Youth

Foster Care

Substance Abuse Programs

Hospitalizations for Mental Health/Substance Abuse Issues

Community Service Agency

Lahey Behavioral Health

Ongoing family/individual therapy

Trauma Focused CBT

Special Education/IEP

Other

If other selected please specify*

Currently, does the youth fall into the descriptions below? Check all that apply.*

Department of Mental Health

Department of Children and Families (foster and adoptive care, formerly DSS)

Department of Youth Services

Physical, cognitive, or learning disabilities

Foreign born youth and youth living in homes where English is not spoken

Youth at Risk of Suicide

Youth living in public housing

Youth living in economically depressed URBAN areas

Youth living in economically depressed RURAL areas

Youth facing neighborhood violence

On track to graduate this year

Attending College next year

Entering Military next year

Other

If other selected please specify*

Please note: Completion of this application is the first step. Youth participation in programming, performances and outside events is at the sole discretion of Express Yourself administration and staff.

I desire to participate in the Express Yourself program located in Beverly, Massachusetts (“Primary site”) and all related activities whether or not located at the Primary site (Hereinafter “Program”). I understand that the entire period of the Program, including travel to and from the Program is included in this release from the date of execution through to and including the date that is the last date related to the culminating performance and activities related thereto.

I promise to act responsibly and will comply with all of Express Yourself policies, standards and instructions for Participant behavior.

I will promptly inform Express Yourself of any and all changes in my treatment/residential program and/ or custodial status.

I give permission to Express Yourself to transport Participant for field trips and activities as part of participation in programming whether by bus, taxi, or transportation for hire.

I acknowledge that Express Yourself photographs artwork created by youth. I understand that the photographed artwork may be reproduced for publication and no personal information will be shared. I understand that the photographed artwork could be used for the purpose of supervision of graduate students, education, and/or research.

I acknowledge and understand that there are certain risks inherent in participating in the Program. These include, but are not limited to, the risks of personal injury, illness or death, property damage or property loss or theft, risks of travel, negligent acts or omissions of Program employees, independent contractors, servants or agents. I acknowledge that I am participating in this Program at my own free will and agree to assume all the risks and responsibilities surrounding my participation in the Program.

I acknowledge that Express Yourself conducts routine Program surveys by youth and agree to participate in such surveys. I understand that the surveys are administered anonymously and no personal information will be shared. Results may be shared with third parties to be used in evaluating program effectiveness and secure program funding.

I hereby agree to assume all of the risks and responsibilities surrounding my participation in the Program. To the maximum extent permitted by law, I hereby release, waive, discharge and hold harmless Express Yourself, its affiliates, officers, directors, faculty, employees, agents, representatives, past or present, and any one claiming by through or under Express Yourself (Hereinafter “Released Party”) from and against any present or future claims, suits, liabilities for any injury to person or property which I may suffer or for which I may be liable to any person arising out of or related to my participation in the Program, including travel to and from my destination resulting from any cause. (Hereinafter “Claims”)

I consent and authorize Express Yourself, Inc. to prepare photographs, videotapes or other moving images and/or audio recordings of the Minor and to use any such recordings in any media (through exhibition, distribution, reproduction, any social media outlet including but not limited to Facebook, Twitter, Instagram or otherwise), which may include the Minor’s name, likeness, image, voice, appearance, and performance. Express Yourself, Inc. shall own such recordings and may edit and use the recordings or excerpts therefrom as it wishes. I hereby waive all rights under publicity, defamation, and proprietary rights relating to any such recordings. Express Yourself, Inc. may transfer or license any of its rights hereunder.

In signing below, I certify that I have read and fully understand the above Acknowledgement, Release, and Assumption of Risk.*

Participant Signature*

Date*

MM slash DD slash YYYY

Parent or Guardian signature (required if participant is under 18 years of age)

Date

MM slash DD slash YYYY

Comments

This field is for validation purposes and should be left unchanged.