Program Participant Intake and Consent Form

Program Participant Intake & Consents
General Information
Participant's Full Name

First NameMiddle NameLast NameSuffix
Parent's Full Name

First NameMiddle NameLast NameSuffix
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Parent's E-mail
Participant's E-mail
example@example.com
Parent's Phone Number

Area CodePhone Number
Participant's Phone Number

Area CodePhone Number
Gender
How did you hear about the program?
What grade is the Participant in?
What is the name and address of the Participant's school?
What is the name of the school district?
What is the Participant's current GPA?
Who is the Participant's current guidance counselor?
What is the guidance counselor's telephone number and email address?
What is the Student ID Number?
It is highly recommended that you authorize What If Ivy Saw's staff member to communicate directly with the Participant's guidance counselor. The Participant's graduation requirements, weighted GPA, etc. must be verified with the school. Matriculation monitoring is essential and monitoring of grades and Participant engagement will be discussed with the counselor. Successful completion of the program depends on open communication between all interested parties.
What is the Participant's intended career goal?
What is the Participant's Top 3 college/university choices?
Personal History
What is the Participant's main interests and/or hobbies?
Does the Participant work?
Does the Participant intend to attend college?
Share anything important that you'd like the program staff to know.
I have read the following documents (are in the pdf version of this intake), fully understand them and agree to their terms (please sign with your cursor below). Documents: Rules & Responsibilities, Acknowledgement and Consent.
Should be Empty:

Program Participant Intake & Consents

General Information

Personal History