How old is the youth? (Our program serves ages 8-18 years old) *
Your answer
Youth's First and Last Name *
Your answer
Youth's gender? *
Your answer
Youth's physical address? *
Your answer
Youth's Date of Birth *
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What school does youth attend? *
Your answer
What grade is the youth in currently? (If it is summer, next school year.) *
Your answer
Youth must be able to commit at least two days per week to remain active. Can this youth commit? *
Parent/Guardian First and Last Name? *
Your answer
Parent/Guardian Cell Phone Number? *
Your answer
Parent/Guardian Email Address?
Your answer
Parent/Guardian Street Address? *
Your answer
What areas can youth use some improvement or needs assistance? *
Required
Please explain in more details about the area of improvement or help needed in more details. *
Your answer
What is the youth's race? *
Are there are specialized services that the youth participate in currently? (Therapy/counseling, speech, etc) *
Your answer
How did you hear about Cultivating Youth? *
Your answer
Any additional information we may need to know? *
Your answer
*
Required
By typing your name below, you acknowledge that you have read, understand and agree to all the terms and conditions outlined in this agreement. Please type your name below. *
Your answer
Today's Date
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A copy of your responses will be emailed to the address you provided.