Enroll — Project THRIVE

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Student & Parent Consent

Both signatures required

By signing below, we agree that the student will participate in Project THRIVE with JD Health & Wellness, in partnership with Salem-Keizer Public Schools, State Grants, and your insurance provider. There is no cost to participate. We understand participation is voluntary and may be stopped at any time.

Student information

Student name *

Date of birth *

School *

Grade *

Street address *

City *

ZIP code *

Student signature *

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Parent / guardian information

Parent / guardian name *

Relationship to student *

Phone *

Email *

Parent / guardian signature *

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Your information is confidential and shared only with the THRIVE team and your school counselor.

Please complete all required fields and sign where indicated.

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Student Consent

You sign for yourself

By signing below, I agree to participate in Project THRIVE with JD Health & Wellness, in partnership with Salem-Keizer Public Schools, State Grants, and your insurance provider. There is no cost to participate. I understand participation is voluntary and I can opt out at any time.

Your information

Full name *

Date of birth *

School *

Grade *

Your phone *

Your email *

Street address *

City *

ZIP code *

Your signature *

Sign here with your finger or mouse

Your information is confidential and shared only with the THRIVE team and your school counselor.

Please complete all required fields and sign where indicated.

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Young Adult Consent

You sign for yourself

Your information

Full name *

Date of birth *

Current situation *

Street address *

City *

ZIP code *

Phone *

Email *

Your signature *

Sign here with your finger or mouse

Your information is confidential and shared only with the THRIVE team.

Please complete all required fields and sign where indicated.

✓

Consent received.

Thanks for enrolling in Project THRIVE. The THRIVE team has been notified, and someone will be in touch within a few days to confirm next steps.

A confirmation copy has been sent to the email address you provided. If you don't see it within an hour, check your spam folder.

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Sign up for Project THRIVE.

Consent received.