Lead the Block Intake Form

Lead the Block: Interest & Intake Form
Personal Information
Full Name*
Age*
Date of Birth*
MM/DD/YYYY
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Preferred Contact Method*

PhoneEmailText
Background Information
Which category best describes you?*

Youth/Young Adult (14-24)Adult Community MemberOrganization Representative
Are you currently:*

In SchoolWorkingBothOther
What languages do you speak (Check all that apply)

EnglishSpanishOther
Community Engagement
How long have you lived in your current neighborhood?*

Less than 1 year1-3 years4-6 years7+ years
Have you participated in community activities before?*

YesNo
If yes please describe
What interests you about becoming a Block Leader? (Check all that apply)*

Making positive change in my communityDeveloping leadership skillMeeting other community membersLearning about community organizingOther
Program Logistics
Can you commit to atending weekly sessions on Thursdays 3 - 5pm for 10 weeks?*

YesNo
If no please explain
Do you need any accomodations to participate fully in the program?

YesNo
If yes please specify
How did you hear about Lead the Block*

Social MediaCommunity OrganizationFriend/FamilySchoolOther
Short Answer Questions
What does community leadership mean to you?
What is one thing you would like to change in your community?
What skills or experiences would you bring to the program?
Emergency Contact Information
Name
Relationship
Phone
For Youth Participants (Under 18)
ParentGuardian Name
Phone
Email
example@example.com
Acknowledgement

I understand that by submitting this form:
- I am expressing interest in the Lead the Block program
- The information provided is accurate to the best of my knowledge
- I agree to participate fully if selected
- I understand that space is limited and submission does not guarantee acceptance
Signature

Clear
Should be Empty:

Lead the Block: Interest & Intake Form

Personal Information

Background Information

Community Engagement

Program Logistics

Short Answer Questions

Emergency Contact Information

For Youth Participants (Under 18)

Acknowledgement