Uncategorized Youth and Teen Services Intake Form Youth and Teen Services Intake Form Step 1 of 4 25% Name* First Last Your Child's Name* First Last Your Child's Date of Birth* MM slash DD slash YYYY Address* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone*Cell PhoneEmail* Preferred Method of ContactEmailHome PhoneCell PhoneName of other Parent/Guradian First Last Phone number of other Parent/Guardian How can we support you?How can our team best support you?What is your child's grade level and what school does your child attend?How did you learn about our programs? Tell us about your child.What are your child's hobbies, special interests, and skills? Does your child receive support from a local agency? If so, please tell us more about what support your child receives. Does your child receive free or reduced price meals? (Please note that this information is helpful for SNSC when applying for grant support; it will not be used in any other way) Does your child have a known diagnosis or a learning disability? Please tell us more. Which of these does your child identify as? (Check all that apply) Indigenous Asian Black or African American Native Hawaiian or Other Pacific Islander Hispanic Middle Eastern White Other Does your child require any accommodations for participating with SNSC? Declaration & PermissionsYes,* I hereby give my permission for Special Needs Support Center to collect and store my personal information. Yes,* I consent to the unrestricted use by the Special Needs Support Center (SNSC) of photographs taken, in whole or in part, unlimited use, for all purposes in any form or medium, including its use through or on any electronic media, including the internet. I also consent to the unrestricted use by SNSC of any corresponding text or audio associated with the pictures. I waive any right to inspect or approve the finished product or products that may be used with the finished photograph(s), including any narrative text that may go along with the photograph. I hereby release SNSC from any and all claims in connection with the photograph(s) and/or corresponding text or audio, including any and all claims of libel. No, I do not consent to the use of my photographs by the Special Needs Support Center. Yes,* I understand that my personal information may be shared with team members at Special Needs Support Center if necessary. CAPTCHA March 5, 2021/by Cortney Nichols https://snsc-uv.org/wp-content/uploads/high-res-logo-300x200.png 0 0 Cortney Nichols https://snsc-uv.org/wp-content/uploads/high-res-logo-300x200.png Cortney Nichols2021-03-05 02:27:222021-10-28 12:05:38Youth and Teen Services Intake Form
Letter to the Community re Diversity, Equity, & Inclusion