AS/Summer Interest Form

Gwen's Girls After School Program

Interest Form
How did you hear about us?

Social MediaSchool ReferralFamily/Friend ReferralCommunity ReferralWord of MouthOther
What after school site are you applying for?

ClairtonNorthsideWilkinsburgI'm not sure
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?

YesNo
Does the youth have an IEP (Individual Education Plan)?

YesNo
Is the youth enrolled in Special Education classes?

YesNo
Are there any specific concerns about the youth's education?
Is the youth involved in any school related activities?

YesNo
If yes, please explain:
Are there any school/community activities that will affect the youth's participation in GG?

YesNo
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.
Email
example@example.com
Print Name of Parent/Guardian
Parent/Guardian Signature

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Date

MonthDayYear
Date
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Gwen's Girls After School Program