CONFIDENTIAL IN-TAKE
Hello, if you would like information about our programs, please fill out this 2-minute in-take and someone will contact you within 24-48 hours. This information will not be given to any agency and/or persons without your permission. Thank you.
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Today's date
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How did you hear about us?
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Facebook
Instagram
Website
Flyer
Non-Profit Organization
Google, Yahoo, Bing, etc.
Referred by Opportunity Program - Live Oak
Parent/Guardian name
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Parent/Guardian Phone Number
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Parent/Guardian Email
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Student/Client First name
*
Your answer
Student/Client Last name
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Your answer
Student/Client Email
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Your answer
Phone number
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Your answer
Known Language(s)
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English
Spanish
Mandarin
Arabic
Other:
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Date of birth
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YYYY
Ethnicity
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Asian
Black/African-American
Hispanic/Latino
Native American
Pacific Islander
White/Caucasian
Other
Age
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Sex
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Male
Female
Prefer not to say
Address
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City
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Antioch
Pittsburg
Brentwood
Bay Point
Oakley
Concord
Pleasant Hill
Walnut Creek
Richmond
Oakland
Clayton
Other:
State
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AL
AK
AZ
AR
CA
CO
CT
DE
FL
GA
HI
ID
IL
IN
IA
KS
KY
LA
ME
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MI
MN
MS
MO
MT
NE
NV
NH
NJ
NM
NY
NC
ND
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WV
WI
WY
Zip code
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Middle/High school (if attending one).
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Antioch High
Deer Valley
Dozier-Libbey Medical
Live Oak
Prospects
Pittsburg
Black Diamond High
Heritage
Liberty
Freedom
Antioch Middle
Dallas Ranch
Black Diamond Middle
Park Middle
Martin Luther King Jr. Jr. High
Hill View Jr. High
Rancho Medanos Jr. High
Not in middle/high school
Other:
Grade
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6th
7th
8th
9th
10th
11th
12th
Out of school/Graduated/Never completed school
Are you currently attending a college, univerity, or trade school
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Los Medanos College
Diablo Valley College
Contra Costa College
Not attending
Other:
Do you have computer access at home?
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Yes
No
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