• Image field 86

  • 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.

  • Update: This form is no longer accepted. Youth must be registered by a Parent or Legal Guardian. Click here to fill out the parent registration form

  • Today's Date*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Birthdate*
     - -
    2 digit month, 2 digit day, 4 digit year
  • how do you describe the youth applicant's race/ ethnicity (check all that apply)
  • Format: (000) 000-0000.
  • Does the youth have Medicaid/Medi-Cal?*
  • Do you have access to a phone, tablet, laptop or desktop computer that you can use?
  • What language are you most comfortable speaking?
  • I have joined this group to...*

  • Tell Us a Little Bit about Yourself

  •

  • How much do the following sentences describe you?

  • I have some who I can share my feelings and ideas with.
  • I know how to get help with family 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.
  • What is the number of people whom you can rely when you need help or support?
  • Rows
  • Should be Empty: