Adolescent Educational Classes
REGISTRATION FORM
Today's Date
*
-
Month
-
Day
Year
Date
Child's Name
*
First Name
Last Name
Child's Date of Birth
*
-
Month
-
Day
Year
Date
Gender
*
Male
Female
Ethnicity (For grant purposes)
*
African American/Black
Asian/Pacific Islander
Caucasian/White
Hispanic/Latino
Middle Eastern
Native American
Address
*
Street Address
Street Address Line 2
City
Please Select
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Phone Number
*
Please enter a valid phone number.
How did you hear about our Educational Classes?
*
Judge
School System
Court Designated Worker
DJJ
DCBS
Parent (Family)
Homeschool Co-Op
Friend
Other
Referrer/Case Worker's Name
*
First Name
Last Name
Does your child have KY Medicaid?
*
Yes
No
Child's Health Insurance Provider
Please Select
WellCare
Aetna
Anthem
Passport Health
Humana CareSource
UnitedHealthcare
Member Number/ID
Which school do you attend?
*
What is child's current home environment?
*
Both Parents
Foster Care
Group Home
Other Family Member
Multiple Family Home
Single Parent
Area of Concern
Does your child receive services from a counselor, court designated worker or child protective services? If yes, please give information as to what services.
*
Has your child ever received counseling?
*
Yes
No
Does your child have a hard time sleeping at night?
*
Yes
No
Does your child have problems with making friends?
*
Yes
No
Did your child exhibit or currently exhibiting any developmental delays?
*
Yes
No
Does your child exhibit problems with self-esteem?
*
Yes
No
Does your child have difficulty respecting personal boundaries?
*
Yes
No
Does your child become anxious or worry frequently?
*
Yes
No
Does your child seem sad or depressed frequently?
*
Yes
No
Has there been a significant change in your child’s appetite (eating more or less)?
*
Yes
No
Has your child displayed a significant change in their sleeping patterns?
*
Yes
No
Has your child exhibited cruelty to animals?
*
Yes
No
Has your child ever exhibited episodes of fire setting?
*
Yes
No
Does your child have difficulty maintaining their hygiene?
*
Yes
No
Has your child exhibited or talked about self-harm behaviors?
*
Yes
No
Has your child exhibited or discussed hurting others?
*
Yes
No
Has your child exhibited any episodes of substance abuse?
*
Yes
No
Is your child exhibiting behavioral problems at school?
*
Yes
No
Parental Contact Info
Parent/Guardian Name
*
First Name
Last Name
What is your relationship to the child (parent, grandparent, foster parent, etc.)
*
Parent
Grandparent
Foster Parent
Other
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Parent/Guardian Email
*
example@example.com
Preferred Method of Contact
Please Select
Email
Phone
Text
No Preference
An active email address is required for participation in all virtual classes with Light of Chance. Please indicate below that you have provided an active email address in this form.
*
I certify that I have provided an active email address in this form.
Parent/Guardian Signature
*
Please verify that you are human
*
Submit
Should be Empty: