SHOP Youth Registration Form

SHOP Youth Registration Form

Thank you for your interest in the SHOP program. Youth and young adults ages 16-21 in the Sacramento, Placer, and Yolo Counties who have been directly affected by untreated mental illness, violence, poverty, homelessness, incarceration, or school failure are eligible to apply.
Today's Date*

MonthDayYear
Date
Name*

First NameLast Name
Birthdate*

MonthDayYear
Date
Gender*
Phone Number*
Please enter a valid phone number.
Gender
Email*
example@example.com
Which SHOP site are you signing up for?*
School Name*
County*
Do you have access to a phone, tablet, laptop or desktop computer that you can use?

Yes, all the timeSometimesNo, not at all
What language are you most comfortable speaking?

EnglishSpanishFarsi/DariRussian/UkrainianOther
What city do you live in?*
I have joined this group to...*

Learn about the topicLooking to meet new people (make new friends)Take better care myselfTake better care of a loved oneOther
What would you like to learn from this program? (1-3 sentences are recommended)*
Specify any allergies you have (food, medicine, seasonal allergies, etc.)*
Specify any dietary restrictions that you have (I only eat halal food, I do not eat pork, dairy free, gluten free, etc.)*
Tell Us a Little Bit about Yourself
How would you rate your overall health? (1 poor, unhealthy , 5 great, no major health concerns)

1 star = poor 5 stars =great
How much do the following sentences describe you?
I have some who I can share my feelings and ideas with.

Very much like meA lot like mesort of like meA little like meNot at all like me
I know how to get help with family problems.

Very much like meA lot like mesort of like meA little like meNot at all like me
I like myself.

Very much like meA lot like mesort of like meA little like meNot at all like me
I can prepare a meal for myself.

Very much like meA lot like mesort of like meA little like meNot at all like me
I think about my choices before making a decision.

Very much like meA lot like mesort of like meA little like meNot at all like me
I have difficulty controlling my anger.

Very much like meA lot like mesort of like meA little like meNot at all like me
I try new things even if they are hard.

Very much like meA lot like mesort of like meA little like meNot at all like me
What is the number of people whom you can rely when you need help or support?

012345More than 5

Below is a list of statements. Please use the answer choices to tell us how much each statement 'is' or 'is not' like you.*

	Not at all like me	A little like me	Sort of like me	A lot like me	Very much like me
I have someone who I can share my feelings and ideas with.
I know how to get help with family problems.
I know how to get help with my personal problems.
I like myself.
I can prepare a meal for myself
I think about my choices before making a decision.
I have difficulty controlling my anger.
I try new things even if they are hard.

I consent for a Health Education Council staff member to provide and offer direct mentorship, program related transportation, case management, emotional support, resource navigation, and other follow-up services as requested/needed. Placing your initials in the box below confirms your consent. (John Doe = JD)*
Should be Empty:

SHOP Youth Registration Form

Tell Us a Little Bit about Yourself

How much do the following sentences describe you?