Parent Intake & Expectations Form

Parent Intake & Expectations Form
How are you joining the Be The Proof Community? (Choose one)
- Section 1 — Parent & Youth Info
- Parent/Gaurdian Name
  
  First NameLast Name
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Youth Name
  
  First NameLast Name
- Youth Age Group
- School
- grade
- Preferred Program site
- Section 2 — Transportation
- How will your youth usually get to class?
- How will your youth usually get home?
- Are you open to carpool coordination with other parents?
- Section 3 — Expectations from this program
- What do you want MOST for your child from this program? (pick up to 3)
- If this program is successful, my child will be blanks* in 3 months.
- Section 4 — Behavior & Support Needs: My youth has difficulty with:
  
  Other
- Has your child been bullied?
- Has your child bullied anyone?
- My youth currently:
- Intake form
- Name
  
  First NameLast Name
- Email
  example@example.com
- Address
  
  Street Address
  
  Street Address Line 2
  
  CityState / Province
  
  Postal / Zip Code
- Birth Date
  
  MonthDayYear
  Date
- Age
- Phone Number
  Please enter a valid phone number.Format: (000) 000-0000.
- Section 5 — Family Stability Snapshot-in the past 6 months, our family has experienced:
- I would like referrals for:
- Section 6 — Participation & Skills . How can you plug in?
  
  Other
- Skills / resources I can offer:
  
  Other
- Other skills continued: blanks
- Section 7 — Donations / Uniform Interest - I am interested in:
- Section 8- Future programming interest
- Signature
- Date
  
  MonthDayYear
  Date
- Please verify that you are human
- SMS/ email messaging
- Should be Empty:

Parent Intake & Expectations Form

Section 1 — Parent & Youth Info

Section 2 — Transportation

Section 3 — Expectations from this program

Intake form