SE Network | Enrollment (Under 18)
Questions? Contact our Intake & Referral Specialist at 206-724-9654
Enrollment Date (Today's Date)
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Month
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Day
Year
Date
Participant Information
Participant Name:
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First Name
Last Name
Participant Date of Birth:
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Month
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Day
Year
Date
Participant Age:
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Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Participant Cell Phone:
Format: (000) 000-0000.
Participant Email:
example@example.com
Participant Gender:
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Male
Female
Nonbinary
Other, specify:
Participant Pronouns:
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He/Him/His
She/Her/Hers
They/Them/Theirs
Other, specify:
Participant School Status:
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Enrolled
Unenrolled
Graduated
Enrolled for GED
Obtained GED
Running Start
Other, specify:
Participant Grade:
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N/A
6
7
8
9
10
11
12
Other, specify:
Participant School Name:
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N/A
Aki Kurose Middle School
Alan T. Sugiyama High School at South Lake
Cleveland High School
Franklin High School
Interagency Academy
Orca K-8
Rainier Beach High School
South Shore K-8
Washington Middle School
Other, specify:
Household Information
Family Setting:
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2 parents/guardians in 1 household
2 parents/guardians in separate households
1 parent/guardian in 1 household
Specify who the participant lives with (select all that apply):
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Both Parents
Mother
Father
Grandparent(s)
Other Relatives
Foster Parents
Friends
Boy/Girlfriend
Couch Surfing
Shelter
Streets
Other, specify:
Household Size (all living at home):
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1
2
3
4
5
6
7
8+
I choose not to answer
Annual Household Income:
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< $20,000
$20,000-$29,000
$30,000-$39,000
$40,000-$49,000
$50,000-$59,000
$60,000-$69,000
$70,000+
I choose not to answer
Other, specify:
Primary language spoken at home:
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English
Other, specify:
Are you or your family currently in transitional housing and/or experiencing homelessness?
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Yes
No
I choose not to answer
Demographics
Participant Race/Ethnicity:
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African Immigrant
American Indian or Alaskan Native
Asian Indian
Black/African American
East Asian
Hispanic/Latino
Arab/Middle Eastern
Multi-Ethnic
Native Hawaiian/Pacific Islander
Southeast Asian
White
I choose not to answer
Other, specify:
Participant First Language:
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English
Other, specify:
Participant Country of Birth:
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United States of America
Other, specify:
Public Assistance:
Free/Reduced Lunch
SNAP/Food Stamps
Temp. Assistance to Needy Families (TANF)
Refugee Cash Assistance (RCA)
Supplemental Security Income (SSI)
Social Security Disability Insurance (SSDI)
Other, specify:
Specify any that apply to this participant:
Foster Care
Kinship Care
Reunited from Foster Care
Adopted
City/Council Housing Authority Resident
Is the participant a member of the LGBTQ+ Community?
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Yes
No
I choose not to answer
School Level and Support:
Individual Education Plan (IEP)
Advanced placement at school
Receiving tutoring
Parent/Guardian Information (required for youth under 18)
#1 Primary Parent/Guardian
Parent/Guardian Name
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First Name
Last Name
Parent/Guardian Gender:
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Male
Female
Other, specify:
Relationship to Participant:
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Parent
Legal Guardian
Grandparent
Aunt or Uncle
Other, specify:
Parent/Guardian Address:
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Same address as participant
Other, specify:
Parent/Guardian Primary Language:
*
English
Other, specify:
Parent/Guardian Phone:
*
Format: (000) 000-0000.
Parent/Guardian Email:
*
example@example.com
#2 Second Parent/Guardian (optional)
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Gender:
Male
Female
Other, specify:
Relationship to Participant:
Parent
Grandparent
Aunt or Uncle
Legal Guardian
Other, specify:
Parent/Guardian Address:
Same address as participant
Other, specify:
Parent/Guardian Primary Language:
English
Other, specify:
Parent/Guardian Phone:
Format: (000) 000-0000.
Parent/Guardian Email:
example@example.com
Submit
Submit
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