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: Gender:–None–MaleFemaleGender Non-Conforming/Non-Binary Race and Ethnicity:African American/BlackAsian/Pacific IslanderCaucasian (Non-Hispanic)Hispanic/LatinxNative AmericanMixed RaceOther Emergency Contact Name: Emergency Contact Relationship: Emergency Contact Phone: Emergency Contact Email: Campus Name:–None–Community-McKinneyCommunity-PlanoJohn R. RoachMedlockYouth Village Program:–None–Career ReadinessCulinary ArtsReentry Support 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:–None–6th7th8th9th10th11th12th 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: