Student Intake

Student Intake

First Name:

Middle Name:

Last Name:

Phone Number:

Email Address:

Social Media:

Home Address:

Home Address is Permanent:

Can Receive Mail:

Have Computer and Internet Access:

Have Smartphone and Internet Access:

Forms of ID Available:

Date of Birth:


Race and Ethnicity:

Emergency Contact Name:

Emergency Contact Relationship:

Emergency Contact Phone:

Emergency Contact Email:

Campus Name:


Has Medicaid:

Has EBT:

Resources Requested:

Favorite Book:

Favorite Celebrity:

Favorite Food:

Favorite Hang-Out Location:

Favorite Movie:

Favorite Musician:

Favorite Sport:

Favorite School Subject:

Favorite Video Game:

Last Grade Completed:

Working On GED:

Has GED:

Name of Last School:

Extracurriculars Attended:

Desired Outcome when School Completed:

Want to do on a Long Day:

Things does Well:

Things dislike Doing:

Things to Improve:

Has been Employed:

Need to Complete Community Service:

Jobs Interested In:

Languages Spoken:

How Youth With Faces can help: