PARTICIPANT INTAKE FORM
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
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The Builder BoTz Summer Program
Participant Name
Participant Address with City, State & Zipcode
Parent/Gaurdian
Emergency Contact
Age
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Birthdate
MM
/
DD
/
YYYY
Race/Ethnicity: (check one)
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Community Area:
Ward
Current Grade
School (or last school attended CPS ID#
Disabled
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Head of Household Information
Family Type: (check one)
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Housing Status: (check one)
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Income Source: (check all that apply)
Source of Referral: (location that sent you)
CHA Client ID#: (if applicable)
Signature of Applicant: (Date):_____________________________________
MM
/
DD
/
YYYY
Intake Worker’s Signature: (Date):_____________________________________
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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.
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Signature* of Parent or Guardian *
MM
/
DD
/
YYYY
Submit
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