Chionesu Bakari Program For Young Men INITIAL INQUIRY QUESTIONNAIRE
Thank you for your interest in the Chionesu Bakari Program For Young Men (CB). Please take a moment to complete this form in its entirety, it will help our staff get a better understanding of your son, his needs and if CB is the best fit for him.

Upon receipt of this completed questionnaire you will be contacted shortly via email.

Interviews with each family and CB Staff are the next step in the process to determine if CB is the right fit for your son and family. You will be notified by email (upon receipt of this questionnaire) as to the availability or status of interviews.

We currently have a waiting list for enrollment.

+W www.youngblackmanonline.org
+E info@youngblackmanonline.org

Your full name (parent/guardian)
Your answer
Your email address
Your answer
Your BEST phone number
Your answer
Your relationship to your son
How many people live in the household with your son?
Please list ALL adults and children as follows: (ie: Adults: 2 / Children: 2)
Your answer
City & State where your son resides
Your answer
Is your son's father or mother present in his life?
If you are married, please select N/A
Your son's full name
Your answer
How old is your son?
Your answer
Your son's birthday
Numerical values only as follows (ie: 1/1/92)
Your answer
Name of your son's school
Your answer
What grade is your son in?
Your answer
Type of school
Has your son ever repeated a grade?
Please list any extracurricular activities your son is involved with/in
Your answer
Has your son ever been arrested?
Has a doctor or health professional ever told you that your son has any of the following conditions?
This information will only be shared with key staff of Chionesu Bakari. Please check all answers that are appropriate.
Required
Does your son have any additional special needs?
Please be specific
Your answer
What form of discipline do you use with your son?
Please check which form(s) you are most consistent with. Do not check more than two (2) answers.
Required
How did you hear about Chionesu Bakari Program For Young Men?
If a current participant, please list their name
Your answer
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