New Youth Survey 2019
Welcome to Kaleidoscope Youth Center (KYC)!

Please feel free to ask a KYC staff member or volunteer any questions you may have as you complete this survey. If you prefer not to answer a question, just type or select "No Answer" as the answer.

The questions are divided into categories: About You, Your Living Situation, Your Education, and You and KYC.
About You
Background information to help us get to know you better :)
Preferred First Name *
Last Name *
Legal Name (First and Last) *
What is your date of birth? (MM/DD/YYYY) *
Please name an Emergency Contact (a trusted adult over 18 years old): *
Best phone number to reach Emergency Contact listed above: *
Emergency Contact's relationship to you: *
What name should we call you if we contact this person? *
Please list any food allergies or dietary restrictions (if none, write No Answer): *
Please list any medical support you require (Examples include: prescription drugs, insulin, EpiPen, et cetera?):
Home Address
City
State
Zip Code (if unknown, answer 43215)
Best phone number to reach you (please indicate if this is NOT your personal cell phone number):
May we leave a text or voice message at this number? *
E-mail Address
How do you describe your gender identity? (Examples include: trans [female/feminine or male/masculine], genderfluid, genderqueer, non-binary, questioning, cisgender [female/feminine or male/masculine], etc.)
What are your preferred gender pronouns? *
Please identify your sexual orientation if you'd like (Examples include: aromantic, asexual, bisexual, gay, lesbian, pansexual, queer, questioning, heterosexual, etc):
Are you of Hispanic or Latinx origin? *
What is your race? *
Do you want or need any support/resources regarding your immigration status?
Clear selection
If you answered yes to the previous question, please list the country in which you were born:
Do you have any sensory issues or sensitivities that we should know about to make the space at KYC more comfortable for you?
If you would like to share more about your answer to the previous question, please do so here:
Do you have any accessibility needs in order to access the space at KYC?
Your Living Situation
These questions refer to your life at home. Feel free to choose not to answer any question you consider to be too personal by selecting "No Answer."
How many individuals (adults and young people) live in your household?
Where do you live? *
With whom do you live?
Clear selection
How safe do you feel from violence or abuse where you live? *
What is your primary source of financial support?
Clear selection
My relationship with my immediate family is best described as:
Clear selection
Please provide any further information about your family life that you feel comfortable sharing or think we should know:
Your Education
If you are currently enrolled in school or an educational program, what is the name of it?
Is there support for LGBTQ+ young people (such as a GSA club, affinity group, or resource center) offered at your educational institution?
Clear selection
You and KYC
This is your opportunity to tell us how you heard about KYC and what programming interests you here!
How did you hear about KYC? (Check all that apply) *
Required
What are your top three social media sites you visit or use?
What are you hoping to get out of KYC programming while you attend? *
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