PARTICIPANT INTAKE FORM

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Girls of Grace Youth Center The Builder BoTz TYPE OF PROGRAM:
AGENCY NAME PROJECT NAME X Out-of-School
 Project Innovation
 CHA
 Mentoring
 MMI
 BHS
 Bridges
 RISE

The Builder BoTz Summer Program

Participant Name

Participant Address with City, State & Zipcode

Parent/Gaurdian

Emergency Contact

Age

Male

Female

Choose not to identify

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Birthdate

YYYY

Race/Ethnicity: (check one)

Asian

Black/ African American

Hispanic/ Latino(a)/ Latinx

Native American/ Alaskan

Hawaiian/ Pacific Islander

White

Other

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Community Area:

Ward

Current Grade

School (or last school attended CPS ID#

Disabled

Yes

If yes, please specify

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Head of Household Information

Family Type: (check one)

Single Parent/Female

Single Parent/Male

Two-parent household

Independent Youth

Youth in Care

Relative

Guardian

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Housing Status: (check one)

Rent

Own

CHA resident/ HCV

Homeless/Shelter

In Temporary Housing

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Income Source: (check all that apply)

Employment

Pension

TANF

Earnfare

Social Security

Unemployment Insurance

Other (SSDI, Child Support,VA Benefits)

Source of Referral: (location that sent you)

CHA Client ID#: (if applicable)

Signature of Applicant: (Date):_____________________________________

YYYY

Intake Worker’s Signature: (Date):_____________________________________

Option 1

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PARENT OR GUARDIAN’S STATEMENT: I certify that the above information is accurate and I give my permission for the above named to participate in this program.

Yes

Maybe

Clear selection

Signature* of Parent or Guardian *

YYYY

Submit

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