THE SUPPORT GROUP PROGRAM INTAKE FORM
Program Interest
*
Summer Employment
Maximum Exposure: College & Career Pathways
Sports Initiatives
Youth Peace Ambassadors in Motion
Other
Please choose what site/program you are registered at.
*
TSG BBALL @ ACCA
TSG BBALL @ Kelvyn Park
TSG BBALL @ CVCA
TSG BBALL @ Beasley
TSG BBALL @ Mather
TSG BBALL @ Wells
TSG BBALL @ Uplift
TSG BBALL @ Richards
TSG BBALL @ Dunbar
TSG BBALL @ Little Village
TSG YPAM
Biz Boot Camp
Name
*
First Name
Last Name
Birthday
*
-
Month
-
Day
Year
Date Picker Icon
Today
-
Month
-
Day
Year
Date Picker Icon
Age - days
Age - Years
Ethnicity/Race
*
Non-Hispanic
Black
Asian
White
Native Hawaiian or Other Pacific Islander
Native Indian/Alaksan Descent
Hispanic
Other
Gender
*
Male
Female
Other
Name of School
*
Grade
*
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
College
College Graduate
GPA
SAT
ACT
NWEA
Email
*
example@example.com
Phone Number #1
*
-
Area Code
Phone Number
Phone Number #2
-
Area Code
Phone Number
What is your plan after HS?
*
4 Year College
2 Year Program/Certificate
Military
Work
Undecided
What area do you need extra support in?
*
Academic/Tutoring
College Choice
Financial Literacy
College/Job Readiness
Creating Plan
Expected Graduation Year
*
Please upload Consent forms
Browse Files
Cancel
of
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
PARENT INFORMATION
Family Type
*
Single Parent/Female
Single Parent/Male
Two-Parent
Independent
Relative/Guardian
Foster
Name
*
First Name
Last Name
Parent Email
*
example@example.com
Parent & Emergency Phone Number
*
-
Area Code
Phone Number
OTHER INFORMATION
WARD#
POLICE DISTRICT
IL STATE DISTRICT
US CONG DISTRICT
CONSENT
Parent Signature
*
Print Name For Consent
*
Initial for Consent
*
Participant Signature
*
Print Name for Consent
*
Initial for Consent
*
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