Student Intake Form
Your dreams matter, and your journey starts here. This form helps us get to know you—your interests, goals, strengths, and aspirations—so we can better support you throughout your Teens with Dreams Inc. experience. There are no right or wrong answers; we simply want to learn more about YOU!
Student Information
Student Full Name
*
First Name
Middle Name
Last Name
Student Age
*
Student Date of Birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Student Gender
Student Email Address
*
example@example.com
Student Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Parent/Guardian Information
Parent/Guardian Full Name
*
First Name
Middle Name
Last Name
Relationship to Student
*
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Method of Communication
Phone
Email
Text
School and Academic Background
High School Currently Attending
*
Current Grade Level
*
Please Select
9th Grade
10th Grade
11th Grade
12th Grade
Intended Graduation Year
Current GPA
What are your strengths?
What areas of growth would you like to focus on?
Goals and Future Plans
Current Level of Motivation for Life After High School
*
Please Select
Very motivated
Somewhat motivated
Need more direction
Planned Path After High School
*
Please Select
4-Year College
Community College
Trade/Technical School
Workforce/Career
Undecided
Career / College Major Interest and Related Experience
Long-Term Goals or Dreams
Areas You Need the Most Help With
*
Choosing a career path
College applications
Scholarships/financial aid
Time management
Confidence/self-esteem
Study skills
Communication skills
Goal setting
Other
If Other, please specify
Top College/University of Interest #1
Top College/University of Interest #2
Have You Started Preparing for College?
*
Please Select
Yes
No
Not sure where to start
Programs You Are Most Interested In
Mentorship Program
College Readiness Program
Career Exploration Program
Leadership Development
Life Skills Workshops
How Often Would You Like to Participate?
Please Select
Weekly
Bi-weekly
Monthly
What Would You Like to Gain from Teens with Dreams Inc.?
Consent, Media Release, and Agreement
Parent/Guardian Name
*
First Name
Middle Name
Last Name
Parent/Guardian Signature
*
Parent/Guardian Consent Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Media Release Permission
Please Select
Yes
No
Emergency Contact Name
First Name
Middle Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Relationship
Student Name
*
First Name
Middle Name
Last Name
Student Signature
*
Student Agreement Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: