Teens for Courage Summit 2024 Waitlist

* Indicates required field
First Name *
Last Name *
Email *
Mobile Phone *
Gender *
Date of Birth *
Name of High School (if homeschooled, please write 'homeschool') *
Current Grade Level *
Emergency Contact Name *
Emergency Contact Phone *
Emergency Contact Relationship *
If 'Other', please specify
I have received permission from my parent/legal guardian to attend this event *
I hereby grant Jamie Kimble Foundation for Courage permission to use my likeness in a photograph in any and all of its publications, including but not limited to all of Jamie Kimble Foundation for Courage's printed and digital publications. *

To serve you better, please answer the following questions which are completely voluntary.

Physical abuse is the only form of Intimate Partner Violence
It's okay for my partner to have access to my social media accounts
If I notice a friend is involved in an abusive relationship, I am likely to tell him/her how I feel about it.
I know who and where to report Domestic Violence/Intimate Partner Violence
I am likely to be involved in a Domestic Violence Awareness program at my school