TESTING PCUL Youth Empowerment Program Form
Complete this optional enrollment/assessment form for the Youth Empowerment Program.
Participant Information
Full Name
First Name
Last Name
Email Address
example@example.com
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Sex
Please Select
Male
Female
Other
Ethnicity
Address
City
State
Zip
Cellphone
Please enter a valid phone number.
Format: (000) 000-0000.
School Information
Name of School
Grade
GPA
Do you have a High School Diploma?
Yes
No
Would you like to receive your GED?
Yes
No
Parent/Guardian Information
Parent/Guardian Full Name
First Name
Last Name
Parent/Guardian Email
example@example.com
Parent/Guardian Phone
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Address
Parent/Guardian City
Parent/Guardian State
Parent/Guardian Zip
Emergency Contact
Emergency Name
Emergency Relationship
Emergency Contact Number
Please enter a valid phone number.
Format: (000) 000-0000.
Goals & Needs
Goals after High School
What are you looking to receive?
Current education barriers
Are you employed?
Yes
No
Do you need resume/job readiness help?
Yes
No
Signatures
Participant Signature
Participant Signature Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Parent/Guardian Signature
Parent/Guardian Signature Date
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Continue
Continue
Should be Empty: