Child/Youth Participant Enrollment Form

CHILD/YOUTH PARTICIPANT ENROLLMENT FORM
PARTICIPANT INFORMATION
Child/Youth Last Name
First
Middle
Date of Birth
Gender
Race/Ethnicity (Please select as many as apply):

American Indian or AlaskanAsianBlack or African AmericanAfrican/Caribbean IslanderHispanic or LatinoMiddle EasternNative Hawaiian/Pacific IslanderWhite (Non-Hispanic)Biracial or MultiracialOther
What is the child/youth's grade level? (Select the grade child/youth will be in this Fall. Please Choose only one. )
Child/Youth's Most Recent School
Child/Youth's School this Fall
Student's ID# (available on the Leon County Schools parent portal or by calling the school)
HOUSEHOLD INFORMATION
Caregiver Last Name
First
Caregiver Phone Number
Please enter a valid phone number.
Is this a mobile phone?

YesNo
Caregiver Email Address
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Language Spoken at Home:
Number of Children ages 0-18 in Household:
Number of Children ages 19-24 living in Household:
Please tell us anything you think it is important for us to know about you and your family's needs to be happy and successful in this program (e.g., learning disabilities, special needs, other):

I give my permission for this information to be shared with the Children's Services Council of Leon County (CSC Leon), a funder of this program. / understand that my child will be asked to complete periodic surveys to measure program quality and impact. All information will remain confidential and participant names will never be associated with the data gathered.
Please tell us anything you think it is important for us to know about you and your family's needs to be happy and successful in this program (e.g., learning disabilities, special needs, other):
I give my permission for this information to be shared with the Children's Services Council of Leon County (CSC Leon), a funder of this program. I understand that my child will be asked to complete periodic surveys to measure program quality and impact. All information will remain confidential and participant names will never by associated with the data gathered.
Name

Caregiver First NameCaregiver Last Name
Caregiver Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

PARTICIPANT INFORMATION

HOUSEHOLD INFORMATION