TRIGGER Intake Form
Welcome to the TRIGGER (True Reasons I Grabbed the Gun Evolved from Risk) Project! We are a youth-led organization dedicated to preventing the spread of the disease of gun violence through positive youth development and public health. Please provide all of the information below to join us and help end this disease!
Youth Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Are you interested in Summer Youth Employment Programming at TRIGGER University?
*
Yes: Share my info with DOES
No: I am/Want to be at another site
Maybe: unsure and need more information
No thank you
Other
If "Other" explain below:
*
Youth Email/iCloud
*
example@example.com
Youth Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent Name
*
First Name
Last Name
Parent Email
*
example@example.com
Parent Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
How many people live in your household?
*
What neighborhood are you from?
*
Are there any neighborhoods you are uncomfortable with?
*
What school do you attend?
*
How many years have you been with trigger and how did you hear about TRIGGER?
*
What is your main source of transportation?
*
Metro (bus/train)
Uber
Parent/Guardian/Older sibling rides
I have my own car
Walking
Other
If other, describe below:
*
Do you have an uber account?
*
Yes
No
What are your NEEDS? (Food, clothing, transportation, cash, etc.)
*
What are your talents/hobbies? (singing/rapping, owning your business, clothing lines, art/drawing, etc.)
*
What are your goals? What do you REALLY want to do? (Go to college, work a certain job, be a millionaire, etc.)
*
Are you in any extracurricular activities in or out of school (Sports, etc.)
*
What is your Cashapp Username? ($ThisIsMyAccount)
*
Do you currently have a job?
*
Yes
No
If yes, where do you work?
*
If no, what are some jobs you would like to have?
*
Hoodie/Jacket Size
*
XS
S
M
L
XL
XXL
XXXL
XXXXL
Shirt Size
*
XS
S
M
L
XL
XXL
XXXL
XXXXL
Sweat Pants Size
*
XS
S
M
L
XL
XXL
XXXL
XXXXL
What is your shoe size?
*
Do you have any allergies or food restrictions?
*
Why do you think youth gun violence happens?
*
What are some ways you think we as a community can prevent (stop from happening) or end youth gun violence?
*
Do you think there is anything YOU can do personally to help stop youth gun violence?
*
Who are some positive adults in your life?
*
Is there anything else we need to know?
*
Signature
*
Submit
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