Youth Support Group
Has your child attended the NAMI Youth Support Group before?
First time attending
Returning participant
Returning participant, but still needs to register
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Youth Support Group
Registration
Date
*
-
Month
-
Day
Year
Date
Time In
*
Hour Minutes
AM
PM
AM/PM Option
Number of children you are registering:
*
Please Select
1
2
3
4
Parent or Guardian
*
First Name
Last Name
Parent or Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent or Guardian Email
example@example.com
Parent or Guardian Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please provide the following information for your Youth
Is there any other information our team should be aware of?
If none, please type "N/A"
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Youth #1 Information
Youth #1 Information
Full Name
*
Age
*
Allergies (if any)
Which most closely matches your child's gender?
Female
Male
Nonbinary, genderfluid, or gender non-conforming
Transgender
Questioning/unsure
They use another term
Prefer not to answer/Unknown
What is your child's race or origin? (Choose as many as you like)
American Indian or Alaskan Native
Asian or Pacific Islander
Asian
Native Hawaiian or Pacific Islander
Black or African American
Hispanic
White
Some other race alone
Two or more races
Prefer not to answer/Unknown
What is your child's ethnicity or where your family or culture is from? (Choose as many as you like)
Hispanic
Puerto Rican
Mexican
Cuban
Other Specific Hispanic Origin
Not of Hispanic Origin
Prefer not to answer/Unknown
Is your child currently in school?
Yes
No
Prefer not to answer
What is their current school level?
Please Select
Kindergarden
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Prefer Not To Answer
What is your child's residential status?
In a house or apartment
I don’t have a regular place to stay (homeless)
In foster care or a foster home
In a group home or residential program
In a crisis shelter or safe house
In a facility like a hospital, treatment center, or juvenile center
Jail/Correctional Facility
Living on my own (independent living — no adult/guardian support)
Living with family, a guardian, or an adult who takes care of me (dependent living)
Prefer not to answer
Do your child have any substance use challenges?
Yes
No
Prefer not to answer
Has your child ever been involved in the justice system?
Yes
No
Prefer not to answer
Youth #2 Information
Youth #2 Information
Full Name
*
Age
*
Allergies (if any)
Which most closely matches your child's gender?
Female
Male
Nonbinary, genderfluid, or gender non-conforming
Transgender
Questioning/unsure
They use another term
Prefer not to answer/Unknown
What is your child's race or origin? (Choose as many as you like)
American Indian or Alaskan Native
Asian or Pacific Islander
Asian
Native Hawaiian or Pacific Islander
Black or African American
Hispanic
White
Some other race alone
Two or more races
Prefer not to answer/Unknown
What is your child's ethnicity or where your family or culture is from? (Choose as many as you like)
Hispanic
Puerto Rican
Mexican
Cuban
Other Specific Hispanic Origin
Not of Hispanic Origin
Prefer not to answer/Unknown
Is your child currently in school?
Yes
No
Prefer not to answer
What is their current school level?
Please Select
Kindergarden
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Prefer Not To Answer
What is your child's residential status?
In a house or apartment
I don’t have a regular place to stay (homeless)
In foster care or a foster home
In a group home or residential program
In a crisis shelter or safe house
In a facility like a hospital, treatment center, or juvenile center
Jail/Correctional Facility
Living on my own (independent living — no adult/guardian support)
Living with family, a guardian, or an adult who takes care of me (dependent living)
Prefer not to answer
Do your child have any substance use challenges?
Yes
No
Prefer not to answer
Has your child ever been involved in the justice system?
Yes
No
Prefer not to answer
Youth #3 Information
Youth #3 Information
Full Name
*
Age
*
Allergies (if any)
Which most closely matches your child's gender?
Female
Male
Nonbinary, genderfluid, or gender non-conforming
Transgender
Questioning/unsure
They use another term
Prefer not to answer/Unknown
What is your child's race or origin? (Choose as many as you like)
American Indian or Alaskan Native
Asian or Pacific Islander
Asian
Native Hawaiian or Pacific Islander
Black or African American
Hispanic
White
Some other race alone
Two or more races
Prefer not to answer/Unknown
What is your child's ethnicity or where your family or culture is from? (Choose as many as you like)
Hispanic
Puerto Rican
Mexican
Cuban
Other Specific Hispanic Origin
Not of Hispanic Origin
Prefer not to answer/Unknown
Is your child currently in school?
Yes
No
Prefer not to answer
What is their current school level?
Please Select
Kindergarden
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Prefer Not To Answer
What is your child's residential status?
In a house or apartment
I don’t have a regular place to stay (homeless)
In foster care or a foster home
In a group home or residential program
In a crisis shelter or safe house
In a facility like a hospital, treatment center, or juvenile center
Jail/Correctional Facility
Living on my own (independent living — no adult/guardian support)
Living with family, a guardian, or an adult who takes care of me (dependent living)
Prefer not to answer
Do your child have any substance use challenges?
Yes
No
Prefer not to answer
Has your child ever been involved in the justice system?
Yes
No
Prefer not to answer
Youth #4 Information
Youth #4 Information
Full Name
Age
Allergies (if any)
Which most closely matches your child's gender?
Female
Male
Nonbinary, genderfluid, or gender non-conforming
Transgender
Questioning/unsure
They use another term
Prefer not to answer/Unknown
What is your child's race or origin? (Choose as many as you like)
American Indian or Alaskan Native
Asian or Pacific Islander
Asian
Native Hawaiian or Pacific Islander
Black or African American
Hispanic
White
Some other race alone
Two or more races
Prefer not to answer/Unknown
What is your child's ethnicity or where your family or culture is from? (Choose as many as you like)
Hispanic
Puerto Rican
Mexican
Cuban
Other Specific Hispanic Origin
Not of Hispanic Origin
Prefer not to answer/Unknown
Is your child currently in school?
Yes
No
Prefer not to answer
What is their current school level?
Please Select
Kindergarden
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Prefer Not To Answer
What is your child's residential status?
In a house or apartment
I don’t have a regular place to stay (homeless)
In foster care or a foster home
In a group home or residential program
In a crisis shelter or safe house
In a facility like a hospital, treatment center, or juvenile center
Jail/Correctional Facility
Living on my own (independent living — no adult/guardian support)
Living with family, a guardian, or an adult who takes care of me (dependent living)
Prefer not to answer
Do your child have any substance use challenges?
Yes
No
Prefer not to answer
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Youth Support Group
Check-in
Date
*
-
Month
-
Day
Year
Date
Time In
*
Hour Minutes
AM
PM
AM/PM Option
Parent or Guardian
*
First Name
Last Name
Please provide the following information for your Youth
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Thank you!
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