Virtual 2020 SELF-ADVOCACY TRAINING Form

Virtual 2021 SELF-ADVOCACY TRAINING
1. Are you the parent or legal guardian? *

Yes No
2. What is your First and Last Name? *

First Name Last Name
3. What is your child's first and last name? *

First Name Last Name
4. What is your phone number? *

Area Code Phone Number
5. What is your email address? *
example@example.com
6. How old is your child? *
7. What school does your child attend? *
8. Please select the option that best applies to your child. *

My child has a 504 plan My child has an IEP My child has another document which verifies that they have a disability
9. Youth must complete the entire program for our organization to remain in compliance with State requirements. The student must complete 10 sessions. *

My child will be able to complete the entire program My child will not be able to complete the entire program
10. Does your child have any allergies? If so please indicate below *
11. What industry is your child interested in? *

Arts and Recreation Educational Services Financial Services Healthcare/Medical Hospitality/Tourism Information Technology Manufacturing Marketing/Public Relations Media/Entertainment Real Estate/Property Retail
12. Does your child have any medical issues that staff should be aware of? Such as a seizure disorder or asthma? If so, please describe below: *
13. Do you provide consent for Career Focus, Inc., to use images and/or video footage of your child for marketing and promotion purposes such as Flyers, Brochures or social media ? *

Yes No
How did you here about our program? *
Should be Empty:

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