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 *
Your answer
Last Name *
Your answer
Legal Name (First and Last) *
Your answer
What is your date of birth? (MM/DD/YYYY) *
Your answer
Please name an Emergency Contact (a trusted adult over 18 years old): *
Your answer
Best phone number to reach Emergency Contact listed above: *
Your answer
Emergency Contact's relationship to you: *
Your answer
What name should we call you if we contact this person? *
Your answer
Please list any food allergies or dietary restrictions (if none, write No Answer): *
Your answer
Please list any medical support you require (Examples include: prescription drugs, insulin, EpiPen, et cetera?):
Your answer
Home Address
Your answer
City
Your answer
State
Your answer
Zip Code (if unknown, answer 43215)
Your answer
Best phone number to reach you (please indicate if this is NOT your personal cell phone number):
Your answer
May we leave a text or voice message at this number? *
Your answer
E-mail Address
Your answer
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.)
Your answer
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):
Your answer
Are you of Hispanic or Latinx origin? *
What is your race? *
Do you want or need any support/resources regarding your immigration status?
If you answered yes to the previous question, please list the country in which you were born:
Your answer
Do you have any sensory issues or sensitivities that we should know about to make the space at KYC more comfortable for you?
Your answer
If you would like to share more about your answer to the previous question, please do so here:
Your answer
Do you have any accessibility needs in order to access the space at KYC?
Your answer
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?
Your answer
Where do you live? *
With whom do you live?
How safe do you feel from violence or abuse where you live? *
What is your primary source of financial support?
My relationship with my immediate family is best described as:
Please provide any further information about your family life that you feel comfortable sharing or think we should know:
Your answer
Your Education
If you are currently enrolled in school or an educational program, what is the name of it?
Your answer
Is there support for LGBTQ+ young people (such as a GSA club, affinity group, or resource center) offered at your educational institution?
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?
Your answer
What are you hoping to get out of KYC programming while you attend? *
Your answer
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