Interest Form
Please take a moment to complete the information below.
Youth Participant Name
*
First Name
Last Name
Parent/Legal Guardian's Name
*
First Name
Last Name
Parent or Legal Guardian Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
How would you like to be contacted?
*
Phone call
Text Message
Email
Other
Tell us about your Youth Participant!
Current Age of youth participant
*
Current Grade of participant
*
School District of participant
*
Which skills would you like them to learn more about? Choose as many as apply;
*
Social & Emotional Literacy (emotional awareness)
Engage in Social & Emotional Support Classes
Identify, Name and Express emotions as they arise.
Mindful Movement, Yoga
Meditation and Breath exercises
Social Awareness
Responsible decision-making skills
Controlling impulse behaviors
Athlete/Team dynamics
Behavioral Awareness & Maturity
Mentoring/Peer Support
Other
What else would you like to share with us??
How did you hear about us?
*
Social Media
School
Faith Based Organization
Online Add
Housing Authority of Frederick
YMCA
Boys & Girls Club
Other
We are excited to get to know you! Click here to schedule a consultation.
*
Today's Date
*
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Month
/
Day
Year
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Thank you for your time! We look forward to connecting with you!
Each 1 Teach 1, Inc. (admin@each1teach1fredco.org)
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