Participant Intake Form Step 1 of 6 16% Confidentiality Statement: All information contained in this form will be considered confidential information. Release of any information will require a signed “Consent to Release” form by the participant. If a referral is made on behalf of the participant, in signing the “Consent to Release” form, the participant is consenting to the information contained in this form to be released to the receiving agency. Name(Required) First Middle Last Address(Required) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Age(Required)Date of Birth(Required) MM slash DD slash YYYY Parent/Guardian's NameRelationship to ParticipantGender(Required) Male Female Nonbinary Prefer not to say Other Race/Ethnicity(Required) Black White Asian Hispanic Pacific Islander American Indian Other Your Email Address(Required) Enter Email Confirm Email Your Phone(Required)What is your preferred method of contact?(Required)EmailTextPhone callLetter/Mailing (home address and ZIP code) Emergency Contact InformationPlease provide the names and contact information for an adult or family member who we could contact if an emergency arises.Contact 1 Name(Required)Relationship to participant(Required)Phone(Required)Address(Required) Street Address City State / Province / Region ZIP / Postal Code Contact 2 Name(Required)Relationship to participant(Required)Phone(Required)Address(Required) Street Address City State / Province / Region ZIP / Postal Code Education & DemographicsAre you currently in school?(Required) Yes No If yes, list name of school:GradeWhat is the highest level of education that you have completed?(Required) Less than High School (No Diploma received) High School Diploma or GED Some College credit (No degree completed) Associate’s degree Bachelor’s degree Master’s degree Are you interested in getting your GED? Yes No Are you currently employed?(Required) Yes No Actively looking Do you currently have a child?(Required) Yes No Currently expecting Do you have a valid driver’s License?(Required) Yes No Do you own an operating vehicle?(Required) Yes No No, but I have reliable daily transportation What is your current living situation?(Required) Living alone Parent(s) / Friend Homeless and actively looking Are you currently on parole or probation?(Required) Yes No If on parole or probation, who is your Probation Officer? Child(ren)NameAgePlease enter a number less than or equal to 17.Does this child reside with you?NameAgePlease enter a number less than or equal to 17.Does this child reside with you?NameAgePlease enter a number less than or equal to 17.Does this child reside with you?NameAgePlease enter a number less than or equal to 17.Does this child reside with you?NameAgePlease enter a number less than or equal to 17.Does this child reside with you?Is there anything else you’d like to share about your child(ren)? Please answer the next three questions.Please note again that all information you share with us is confidential.Please list 2 short term goals (30-60 days).(Required)Please list 2 long term goals (6 months to 1 year).(Required)What are some areas you need assistance with?(Required) Photography waiver(Required)Please check the appropriate option: Yes, you may take and use my photo or name in Springfield Urban League & Collaborative partner publications. No, please do not take my photo or use my name in Springfield Urban League & Collaborative partner publications. Consent(Required)I give permission to the Springfield Urban League, Inc. and its designees to collect data, record data, receive any treatment by an accredited hospital and/or physician deemed necessary in case of an emergency. I understand all reasonable safety precautions will be taken at all times by the SUL staff and volunteers during events and activities. The data gathered is not restricted to the following: Surveys and/or interviews about his/her knowledge, attitudes, skills, and behaviors in regard to his/her academic development, career aspirations, connection to the community, and overall satisfaction with the School-Age & Community Youth (S.A.Y.)/Workforce Development programs. An academic assessment and school data releasing grade point average, report card, school attendance rate, and graduation information via District 186 Intranet (student/client cumulative folder). SUL is pleased to provide programs and activities as part of its education and Youth/Workforce development programs. Participants in program and activities contingent upon the participant’s appropriate moral and ethical behavior. Any Participant not conducting himself/herself in this manner at any program or activity will be required to leave the program or activities at the expense of the parent when so informed by the event leaders in whose care the participant has been entrusted. I understand that the purpose of this questionnaire and interview is to document the impact of the programs on its participants and to identify areas for improvement. I also understand that this information will remain private and that only the SUL staff will be able to look at his/her response. My signature indicates that I fully understand this program guidelines described above, and the information I provided on this application/assessment is true and correct. I consent to participation as outlined above.Signature
