Youth Voices Network

The Youth Voices Network unites survivors of youth dating abuse under the age of 30 by creating opportunities for survivors to connect, speak about their experiences, and raise community-wide awareness of the issue – all while fostering personal growth and healing. YVN is committed to building a safe and non- judgmental space for a diverse community of survivors of teen dating abuse, including individuals of any gender, race, class, ethnicity, country of origin, religion, or sexual orientation.

Youth Voices members join a community of fellow survivors who are building their public speaking, advocacy and leadership skills by taking action against dating abuse. Member’s experiences have the potential to save lives by raising knowledge about domestic violence and resources for help and their advocacy with legislators and leaders impacts attitudes and leads to policy change. The Youth Voices Network is a Day One initiative that builds safer communities by linking survivors with at-risk youth.

The Youth Voices Network raises awareness in a variety of ways, including: . Sharing personal stories of survival - anonymously or not – with: o Youth/peers o Parents o Teachers o Government officials o Journalists and other media professionals

. Strategizing to raise awareness of relationship abuse among youth through: o Public events o Outreach to organizations o Local and national media attention

By becoming a member of the Youth Voices Network, members can expect to:  Maintain open communication with program coordinator  Join a community of fellow survivors to promote peer social support  Engage at a level they feel most comfortable . Build public speaking and advocacy skills to speak out against dating abuse . Raise young people’s awareness of domestic violence and resources for help . Educate legislators, and influence leaders who make decisions on domestic violence laws.

**As a member of Youth Voices Network, you choose your level of participation at all times. On a case by case basis, members can choose whether or not to use their name, show their face, and/or be photographed/videotaped.**

Please contact Nicole D’Avino and Monica Maya, YVN Co-coordinators at [email protected] with any questions, comments or concerns.

WWW.DAYONENY.ORG Youth Voices Network Application

Contact Information Name: ______Street Address: ______City: ______State: ______Zip Code: ______Home phone: ______Work phone: ______Cell phone: ______Email: ______Birthdate: ______Gender: ______

Education, Employment and Volunteer Experience Are you presently employed?  Yes  No Occupation/Job Title: ______Employer’s Name: ______Are you presently in school?  Yes  No High School/Graduation Date: ______College/Major/Graduation Date: ______Graduate School/Major/Graduation Date: ______

Emergency Contact Information Please provide us with contact information for two people to contact in the event of an emergency:

Primary Contact Name: ______Relationship: ______Home Phone: ______Work Phone: ______Cell Phone: ______Email: ______

Secondary Contact Name: ______Relationship: ______Home Phone: ______Work Phone: ______Cell Phone: ______Email: ______

How did you hear about Day One and/or the Youth Voices Network? ______Why do you want to volunteer with us? ______

WWW.DAYONENY.ORG Background Information and Consent Form Please read carefully before signing. If you have questions about this consent form, please contact Day One.

I am applying to participate in Day One’s Youth Voices Network. I acknowledge and agree that the nature of th e Youth Voices Network activities which are typically performed by Day One volunteers, and which may be perf ormed by me as a Day One volunteer, may involve (a) contact with unidentified and unfamiliar persons, (b) trav el to and from various unspecified locations, and (c) other potential risk of injury. Notwithstanding the precedin g sentence, I willingly and freely agree to volunteer and hereby assume any and all risk, with respect to any lia bility of Day One for such risk, including without limitation risk of any accident or injury to person or property wh ich I may sustain in connection with my participation as a Day One volunteer or in any Day One related project or activity.

I understand that: (1) I am not obligated, if called upon, to perform the volunteer services applied for, and (2) Day One is not obligated to assign, or to actively seek to assign me to a volunteer position. I understand that if I give false information to Day One I will not be accepted or continued as a volunteer.

Have you ever been convicted of a crime?  Yes. If Yes, please explain on a separate page.  No. I hereby confirm, represent and warrant that I have never been convicted of a violent crime, child a buse or neglect, child pornography, child abduction, kidnapping, rape or sexual offense, nor have I ever been ordered by a court to receive psychiatric or psychological treatment in connection herewith.

Are you currently involved in a legal case of any kind, anywhere within or outside of the United States?  Yes. If Yes, please explain on a separate page.  No.

In order to participate in Youth Voices Network, I understand that Day One is required to run a personal backgr ound check and that past convictions do not automatically disqualify me. If I have any concerns about this I will speak with the Youth Voices Coordinator.

______Applicant’s Signature Date

Thank you for your interest in joining the Youth Voices Network. We appreciate your assistance in com pleting this application. Please return this form to [email protected].

Youth Voices Network Interests Survey

WWW.DAYONENY.ORG What qualities do you have than you think can benefit Youth Voices Network? ______Please list skills or experience inside and outside your professional area that you are willing to bring to your work with Youth Voices Network (e.g. graphic design, art, computers, etc.): ______Language Skills: Are you fluent in a language other than English?  No  Yes: ______What are you looking to gain from being a member of Youth Voices Network? ______How can Youth Voices Network best support you? ______

Youth Voices Network Activities The list of possible activities below is to determine what type of activities members are interested in participating. No one is required to take part in specific activities or to disclose any personal information to the public.

 Public Speaking / Advocacy  Special Events Planning I am interested in sharing my story, either anonymo I would like to help plan events that raise usly or not, with the media, with youth and peers, p awareness of the issue of teen dating violence. arents, teachers, or government officials.  Strategizing  Share Your Story in Writing I would like to help strategize to reach out to local I am interested in sharing my story in my own word and state politicians and other leaders and groups s. to raise awareness of the issue

Is there anything you think is missing from this list? Please feel free to share any ideas: ______

Safety Assessment

The following safety assessment is not exhaustive, but is designed to help you consider your level of safety. These factors will be reevaluated periodically in order to ensure the continued safety of everyone involved with the organization.

I. Time Out of Relationship

A. How long have you been out of your relationship? ______

WWW.DAYONENY.ORG B. Are you still in contact with your abuser? Y/N

i. If Yes, what type of communication exists? ______

______

ii. If No, how long has it been since last contact? ______

II. Continued Ties to Former Partner A. Are you and your former partner residing or participating in the same community (religious, ethnic, etc.) ______B. Do you or your former partner have continued ties to each other’s families? Y/N C. Do you and your former partner have friends in common? Y/N D. Do you attend to the same school? Y/N E. Do you have children in common? Y/N i. If Yes, please explain custody, visitation, communication, etc. with former partner: ______

III. Relationship History A. What types of abuse (physical, emotional, sexual, technological, financial, etc.) did you experience? Which types of experiences are you willing to talk about in presentations, interviews, etc? ______B. Since leaving your partner, have there been any incidents of stalking, harassing, etc? i. If so, please explain: ______

IV. Risk Level Assessment A. Does your former partner have a criminal history? ______B. Has your former partner been charged with or convicted of a violent crime? ______C. Does your former partner carry or have access to weapons? ______D. Has your former partner used weapons against you or others? ______E. Did your former partner threaten to use violence against you? Against anyone else, including him/herself? ______H. Was or is your former partner involved in a gang or any similar criminal group? ______

V. Safety Planning

WWW.DAYONENY.ORG A. Does your former partner have your current telephone number, address, email, social networking sites, etc? ______B. Have you ever made/ do you have an up-to-date safety plan? Y/N i. If not, is this something you are interested in? Y/N C. What has worked to help keep yourself safe? ______E. Are your passwords for email/social networking sites are confidential? Y/N

VI. Professional Services A. Have you been to counseling or utilized other therapeutic services? ______i. If yes, what was this experience like for you? ______ii. If no, are you interested in any referrals? ______B. Have you sought legal assistance? ______C. Have you received an Order of Protection? (Criminal or Civil) ______i. When does the Order end? ______ii. Has the order been violated? If yes, how many times? ______D. Has there been a criminal case against your former partner for the abuse? Y/N Please explain:______iii. Did you testify? ______

Other Relevant Information: ______

WWW.DAYONENY.ORG