Teen SpeakUp Registration Form

Section 1: Camper Information

First Name *

Preferred Name *

Gender Identity *

Last Name *

Date of Birth *

School Attending *

Grade Level (Fall 2025) *

Section 2: Parent/Guardian Information

First Name

Last Name

Relationship to Camper *

Phone *

Email *

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Zip / Postal Code

Country

Emergency Contact (if different) *

Phone *

Section 4: Permissions & Waivers

Consent *

I hereby give permission for my child to participate in the TeenSpeakUp Youth Empowerment hosted by Tabula Rasa Domestic Violence, Inc. I understand that this program is trauma-informed and may involve discussions around healthy relationships, self-expression, and personal development. I give permission for staff to seek emergency medical treatment if necessary.

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