SOC Enrollment Form

Organization(Required)

Name(Required)

First Last

Job Title(Required)

Email(Required)

Phone(Required)

Your Role

Please answer the following questions to help us understand your role, experience, and background. This information will help us connect peers within the cohort.

1. Roughly how many years of work experience do you have in organizations and/or roles like the one you are in now?(Required)

Less than 1 year

1-4 years

5-10 years

More than 10 years

2. In just a few words, how would you describe your job responsibilities?(Required)

3. In your role, do you work primarily with youth or adults?(Required)

Youth

Adults

About half and half

Other

If you marked "Other," please describe:

4. If you work with youth, what is the age of MOST of the youth you work with?(Required)

Under 5 years old

5-12 years old

13-18 years old

Over 18 years old

Do not work with youth/Work with adults only

5. Do you supervise staff?(Required)

Yes

Other

If you marked "Other," please explain:

6. Do you make policy and/or strategy decisions for your organization?(Required)

Yes

Other

If you marked "Other," please explain:

7. In what setting does your organization work with youth MOST of the time?(Required)

One-on-one setting

Group setting

Equal amounts of one-on-one and group interactions

Other

If you marked "Other," please explain:

8. Roughly how many paid staff members (full-time and part-time) work at your organization?(Required)

0-4 staff members

5-20 staff members

21-50 staff members

More than 50 staff members

9. Anything else you’d like to tell us about your role / comments:

(Optional)

Dietary Preferences

Please let us know of any dietary preferences or food allergies we should be aware of.

Please list any dietary preferences or food allergies here:

Media Release

Center for Safe Alaskans' program, the Anchorage Youth Development Coalition, needs permission to use a person’s photograph, voice, and/or name in various media projects. This is necessary for projects that produce a form of media, like photos or videos, which may be a product of the project or necessary to share the story of the initiative. For and in consideration of the opportunity and privilege of appearing in or participating in one or more video or audio recordings, sound tracks, films, photographs, or written articles, I hereby consent to the use and editing thereof and release the Center for Safe Alaskans and its Anchorage Youth Development Coalition employees and assignees from any and claims resulting from such use and editing in media, and use, sale, editing and release to the newspapers, radio and television stations; and use on the Internet.

I agree with the media release.(Required)

Yes (If yes, please sign below.)

Signature – If you agree to consent to AYDC's media release, please sign here.

Fee Payment

Full Participant Rate - $200

AYDC Contributing Member Participant Rate - $150

My Organization will send a check directly.

Other (check here if you think your fee is waived or you are unable to pay at this time)

If you marked "Other," please explain:

Payment Method

MasterCard

Visa

Card Number Expiration Date Security Code Cardholder Name

Second Order Change Enrollment Form 2023

Your Role

Dietary Preferences

Media Release

Contact Us

Center for Safe Alaskans