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
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Month
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Day
Year
Date
Name
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First Name
Last Name
Birthdate
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Month
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Day
Year
Date
Gender
Phone Number
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Please enter a valid phone number.
Email
*
example@example.com
Which SHOP site are you signing up for?
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Please Select
Mack Road Community Center
Robertson Community Center
Swanston Community Center
Mira Loma HS
Liberty Towers Community Center
School Name
Do you have access to a phone, tablet, laptop or desktop computer that you can use?
Yes, all the time
Sometimes
No, not at all
What language are you most comfortable speaking?
English
Spanish
Farsi/Dari
Russian/Ukrainian
Other
What city do you live in?
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I have joined this group to...
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Learn about the topic
Looking to meet new people (make new friends)
Take better care myself
Take better care of a loved one
Other
What would you like to learn from this program? (1-3 sentences are recommended)
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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
2
3
4
5
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 me
A lot like me
sort of like me
A little like me
Not at all like me
I know how to get help with family problems.
Very much like me
A lot like me
sort of like me
A little like me
Not at all like me
I like myself.
Very much like me
A lot like me
sort of like me
A little like me
Not at all like me
I can prepare a meal for myself.
Very much like me
A lot like me
sort of like me
A little like me
Not at all like me
I think about my choices before making a decision.
Very much like me
A lot like me
sort of like me
A little like me
Not at all like me
I have difficulty controlling my anger.
Very much like me
A lot like me
sort of like me
A little like me
Not at all like me
I try new things even if they are hard.
Very much like me
A lot like me
sort of like me
A little like me
Not at all like me
What is the number of people whom you can rely when you need help or support?
0
1
2
3
4
5
More 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.
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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)
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Submit
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