NYA Youth/Teen Support Group (Ages 12-17 years old) Registration

This group is dedicated to supporting and connecting youth between the ages of 12 -17 years old. This group will have two options to meet monthly and will be asked below. A link to join will be sent to the email provided each month. If you have any questions, please contact MaryAnn Emerick at memerick@hdsa.org

First Name *

Email Address *

Last Name *

State *

Email for youth to join group *

Phone *

Date of Birth * +

Please check off which you are able to attend. *

First Saturday of the month at 12pm EST

Third Tuesday of the month at 7pm EST

What are some questions you have or topics you would like to discuss? *

Contact Information of Parent/Guardian and Consent for Participation

*Consent for participation form will be sent to parent/guardian in addition to signature below.

Name of parent/guardian *

Phone *

Email *

Release of Liability from parent/guardian: I am aware that during the group discussion facilitators and attendees will be discussing Huntington’s disease, and youth issues related to Huntington’s disease, including but not limited to mental health, disease progression, dating and relationships, and sharing family stories related to Huntington’s disease. Personal information shared will be kept confidential, with exceptions of reports of abuse, neglect, or intent to harm self or others as required by law. By signing, I allow participation and acknowledgement of topics possibly discussed. *

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