Youth Cultural Enrichment Program

Guiding Hearts, Inspiring Journeys, and Empowering Lives

The Youth Cultural Enrichment Program is a community-based initiative that supports the social, emotional, and cultural development of youth ages 8–17. Through creative expression, life skills development, and cultural exploration, participants build confidence, strengthen communication, and deepen their understanding of their identity.

The program integrates arts, mentorship, and real-world exposure to create a safe and engaging environment for growth. More than enrichment, it is a space where youth are empowered to connect, express, and thrive.

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Participant Information

Participant Information

Participant Name

Date of Birth

Age

Gender

Parent/Guardian Information

Parent/Guardian Information

Parent/Guardian Name

Relationship

Phone Number

Email Address

Emergency Contact (If different)

Emergency Contact (If different)

Name

Phone Number

Relationship

Medical & Safety Information

Medical & Safety Information

Does your child have any medical conditions?

Yes

No

If yes please explain

Allergies (food, medication, environmental):

Is your child currently taking medication?

Yes

No

If yes, please list

Behavioral & Emotional Considerations (To help us best support your child)

Behavioral & Emotional Considerations (To help us best support your child)

Has your child experienced any of the following? (Check all that apply)

Anxiety

Depression

Trauma exposure

Behavioral challenges

Difficulty with Peer Relationships

Other

Consent & Agreement

Consent & Agreement

Consent & Agreement

I, the undersigned parent or legal guardian, hereby grant permission for my child to participate in the Youth Cultural Enrichment Program by The Butterfly Effect Trauma Response & Treatment Foundation (BFE Foundation).

I acknowledge that participation in this program involves physical activity, including dance, and group-based engagement, including theater, which may carry inherent risks of injury or emotional discomfort.

I understand that while BFE Foundation will take reasonable precautions to ensure the safety and well-being of all participants, accidents or unforeseen incidents may occur. By signing below, I voluntarily assume all risks associated with my child’s participation and agree to release, waive, and hold harmless BFE Foundation, its staff, volunteers, and affiliates from any and all claims, liabilities, damages, or expenses arising from participation in the program, except in cases of gross negligence or willful misconduct.

I affirm that my child is physically and emotionally able to participate in program activities and that I will inform BFE Foundation of any relevant medical, behavioral, or psychological conditions that may impact their participation.

Parent/Guardian Signature

Date

Media Release

I give permission for photos/videos to be taken and used for program promotion

I do NOT give permission

Upcoming Events

Mentor/Mentee Training

Training / Workshops

Dance & Theater Camp

Guiding Hearts, Inspiring Journeys, and Empowering Lives

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