WICAP Youth Intake Form
Personal Information
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Youth Advocate
County
Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Ethnicity
Race
Support Needs
Support
Please Select what You Would Like Assistance With:
GED Information
Tutoring
Counseling Services
Driver's License
Drivers ED
ID Card
Birth Certificate
Volunteer
Leadership
Resume Building
Job Search
Social Security Card
Youth MOVE
Utility Assistance
Rental/Mortgage
Gas Vouchers (Employment and Medical Appointments)
Emergency Hotel Stay
Baby Care Items
Budgeting
TEFAP-Emergency Food
Head Start/Early Head Start
Child Care
LAUNCH
Other Needs
WICAP YOUTH inspires emerging leaders to be their very best. You will gain concrete skills that will be vital for your future. Our free Youth Development program focuses on leadership development, community service, job readiness, school readiness, mental health awareness and diversity support. By participating in WICAP Youth you will be asked to give back to your community. This may come in different forms of volunteering such helping seniors, making cards, making food boxes etc. By signing you are acknowledging and agreeing to give back.
Print Name
Date of Signature
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Household Information
Household Information
Parent Signature
Printed Name
Date of Signature
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Household Monthly Income
Household Family
Rows
First Name
Last Name
Date of Birth
Relationship
Phone Number
1
2
3
4
5
6
7
8
9
10
Do you Currently Have Insurance?
Yes
No
Provider
Please Check All that Apply
Cash Benefits
Food Stamps
Currently Homeless
Foster Care
Notes
Client Demographic
Submit
Should be Empty: