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Enrollment Form

Youth Name:
Date of Birth
Age:
Sex: Male
Female
Ethnicity White
Hispanic
African American
Indian
Name of Parents:
Phone:
Address:
Emergency Contact:
Phone:
Support Person/s:
Phone:
Religious Preference:
Home Church Contact Name:
Phone:
School Name:
Phone:
Last Grade Completed:
IEP Yes
No
Please Explain:
What do you feel are youths most important needs? Choose as many as apply. High School Completion
GED Preparation
College Application
College Funding
Job Search
Budgeting / Saving
Job Training
Summer Employment
Social Skills
Mental Health Counseling
Managing Medications
D&A Counseling
Positive Peer Involvement
Appropriate Recreational Activities
Life Skills (cooking, laundry)
Health
Presenting Problems or Concerns Has youth experienced any of the following behaviors in the past year. Identifying problems enables us to better plan for future success. Substance Abuse
Depression
Suicidal Tendencies
School Absences
Delinquent Behavior
Assault
Incarcerations
Currently on Probation
Teen Pregnancy
Sexually Inappropriate Behavior
Substance Abuse Type and Frequency:
Suicidal Attempt Dates:
School Absences - Number of days missed in last month and explanation for absences:
Delinquent Behavior Please Explain:
Assaults - List Victims and any Restricted Contacts:
Incarceration Dates:
Probation Restrictions:
Teen Pregnancy - Number of Children:
Sexually Inappropriate Behavior - Explain:
Medical Insurance name (A copy of your medical/dental health insurance if available to youth will be needed):
Card Number:
Primary Physician:
Phone:
Allergies:
Medications (please attach a detailed list to include dosages):

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