Parent Intake & Expectations Form
How are you joining the Be The Proof Community? (Choose one)
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Please Select
Parent/Guardian of youth participant
Community supporter (no youth enrolled)
Volunteer / Mentor
Parent & Youth Section
Section 1 — Parent & Youth Info
Parent/Gaurdian Name
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First Name
Last Name
Phone Number
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Please enter a valid phone number.
Youth Name
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First Name
Last Name
Youth Age Group
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Please Select
5-7
8-12
13-19
School
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grade
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Preferred Program site
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Please Select
Hamilton Park
Lindblom Park
Washington Park
Section 2 — Transportation
How will your youth usually get to class?
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Please Select
Parent Drop Off
Youth walks
Public transit
Needs transportation help
How will your youth usually get home?
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Please Select
Parent pick up
Youth walks
Public transit
Needs transportation help
Are you open to carpool coordination with other parents?
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Yes
No
Maybe
Section 3 — Expectations from this program
What do you want MOST for your child from this program? (pick up to 3)
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Fitness & Health
Discipline & Focus
Confidence
Anger control
Staying out of trouble
Social skills & workforce pipeline
If this program is successful, my child will be
blanks
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in 3 months.
Section 4 — Behavior & Support Needs: My youth has difficulty with:
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Staying focused
following directions
anger/emotional regulation
conflicts with peers
anxiety/shyness
none of the above
Other
Has your child been bullied?
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yes
no
prefer not to answer
Has your child bullied anyone?
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yes
no
prefer not to answer
My youth currently:
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has an IEP/504 plan
recieves counseling
takes medication
none of the above
Intake form
Supporter/Volunteer
Name
First Name
Last Name
Address
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Birth Date
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-
Month
-
Day
Year
Date
Age
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Phone Number
Please enter a valid phone number.
Section 5 — Family Stability Snapshot-in the past 6 months, our family has experienced:
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housing instability
food insecurity
transportation barriers
court/legal involvement
none of the above
prefer not to say
I would like referrals for:
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counseling/therapy
employment help
food support
housing support
legal resources
none right now
Section 6 — Participation & Skills . How can you plug in?
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Volunteering
check-in table
event setup/ cleanup
snack support
field trips
chaperone
Not able at this moment
Other
Skills / resources I can offer:
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coaching/fitness
snacks/water
photography/video
graphic design
website help
fundraising / sponsorship connections
small business ownership
mentoring
clerical
mental health / education background
trades (plumbing/electrical/auto)
driving youth
grant-writing assistance
security
N/A
Other
Other skills continued:
blanks
Section 7 — Donations / Uniform Interest - I am interested in:
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purchasing program uniform
sposoring another youth
monthly donation partner
business sponsorship
not right now
Section 8- Future programming interest
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wrestling/ jiu-jitsu
SAT/ACT prep
financial literacy
mentoring groups
entrepreneurship training
workforce pipeline
field trips & travel
family fitness days
Signature
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Date
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-
Month
-
Day
Year
Date
Please verify that you are human
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