RALC: Student Information Sheet
Student Name *
Your answer
Date of Birth *
MM/DD/YYYY
Your answer
Age *
Your answer
Expected Graduation Date *
Year
Your answer
Graduating School *
Home Address *
Your answer
I live with *
(example: Parents, grandparents, aunts, uncles)
Your answer
Is this living arrangement working for you? *
Your answer
Parent/Guardian #1 *
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian Phone Number *
Your answer
Parent/Guardian #2 *
Your answer
Parent/Guardian Address *
Your answer
Parent/Guardian Phone *
Your answer
Parent/Guardian email *
Your answer
Student Address *
Your answer
Student phone *
Your answer
Name of county worker
Your answer
Name of probation officer
Your answer
Name of social worker
Your answer
Do you have free/reduced lunches? *
Do you need a form to apply for free/reduced lunches? *
Would you like to see a therapist? *
Do you currently see a therapist? *
If yes, where do you go to therapy? *
Your answer
If yes, name of therapist?
Your answer
Do you have health insurance? *
Do you need help with ?
What can we do to help? *
Your answer
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