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SHOP

Event Registration

SHOP Registration

Student Information
Contact Info
Country
Address Line 1
City
State/Province
Postal Code
About You
Month
/
Day
/
Year
Race (Select one or more races)
Have you ever witnessed or experienced any of the following events? If you have experienced any of these events, you may be eligible for victims' crime compensation. Select all or any that apply to you. 
(Your answers will be anonymous and kept confidential.)
Parent/Guardian Information (please fill out if applicant is under 18 years old.)
Emergency Contact
Do you have access to a phone, tablet, laptop or desktop computer that you can use?
How did you learn about SHOP?
Permission Form for Photo/ Video/ Filming

I authorize and give permission that the Health Education Council photograph and video tape or film my child, and I as well, as long as my children participate in the program. I recognize that neither I, nor my children will be compensated by the center or by a third person for the use of the images. I give permission to the Health Education Council to use the images to demonstrate program impact on several social media, including, but not limited to Health Education Council’s website, Facebook, and Instagram pages, the newsletters, and the websites of the Office of Minority Health, Community-Oriented Policing Services, and the Center for Court Innovation.

Permission for Home Delivery/Visits

I consent for a Health Education Council staff member to conduct a home delivery or home visit for the purpose of offering direct mentorship, case management, emotional support, resource navigation, and other follow-up services at my residence. 

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