AS/Summer Interest Form

Gwen's Girls After School Program

Interest Form
How did you hear about us?

Other
What after school site are you applying for?
CLIENT INFORMATION

The information collected is internally reviewed and helps secure grant funding for programs and events.
Youth's Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Age:
SCHOOL INFORMATION
School:
Grade:
Is the youth currently enrolled in school?
Does the youth have an IEP (Individual Education Plan)?
Is the youth enrolled in Special Education classes?
Are there any specific concerns about the youth's education?
Is the youth involved in any school related activities?
If yes, please explain:
Are there any school/community activities that will affect the youth's participation in GG?
If yes, please explain:
Parent/Guardian Information
Name of Parent/Guardian:

First NameLast Name
Relationship to youth:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com
Print Name of Parent/Guardian
Parent/Guardian Signature
Date

MonthDayYear
Date
Should be Empty:

Gwen's Girls After School Program