Caregiver Intake Questionnaire
BASIC ELIGIBILITY
To be eligible and enroll, a child must:

• Have an immediate family member who is currently or recently incarcerated in jail, prison, immigration custody, on probation or parole, or otherwise involved with the criminal justice system.This incarceration should be emotionally significant to the child.
• Must be ages 8 to 10
• Must live in Alameda, Contra Costa, San Francisco, Solano, Sonoma or Marin Counties

It's important at least one adult (best if a family member or caregiver) can support the child through the application process. This includes filling out forms for camp and year-round programs, signing permission slips, making sure child is packed and ready for camp, and getting to our van pick-up and drop-off spots on time (during camp / year-round programs).

This intake questionnaire will take 15-20 minutes, is confidential and will only be seen by authorized staff. It includes personal information to help us better understand the needs of your child. An Avary staff will follow-up with a phone call if they have further questions.

Project Avary - Our Story
Description of Our Program
Project Avary improves life outcomes for children with parents in prison or jail. We make a 10-year commitment to each child providing long-term support and training that help children develop emotional, social, and life skills that are important for growing into healthy young adults. Project Avary is a free year-round program that provides support and guidance to children and their caregivers. We have a summer camp, monthly outing program during the school year, Teen Leadership Program and family outings.
CAREGIVER INFORMATION
Name of Caregiver *
Your answer
Relationship to child *
Required
Mailing Address *
Your answer
Phone number *
Your answer
Best time to contact *
Required
Email
Your answer
Language(s) spoke at home?
Your answer
How did you hear about our program? *
Your answer
Why do you think your child would benefit from our program? *
Your answer
CHILD'S INFORMATION
Child's Name *
Your answer
Sex *
Required
Birthdate *
MM
/
DD
/
YYYY
Age *
Required
Ethnicity *
Required
Current School *
Your answer
Current Grade *
Your answer
Does the child have siblings? If so, how many and do they live together or have regular contact? *
Your answer
REFERRING THIRD PARTY INFORMATION
To complete the intake process, Project Avary needs to speak to a third party such as a teacher, social worker, or therapist who is familiar with your child’s behavior outside of the home. This person should not be a family member. Please contact this person and let them know we will be contacting them or to request that they contact us.
NAME OF REFERRING PROFESSIONAL *
Your answer
Title/position *
Your answer
Name of agency/school *
Your answer
Mailing Address *
Your answer
Phone number *
Your answer
Best time to contact *
Required
Email
Your answer
Family Background Information
Project Avary wants every child to have a positive experience. Information you provide helps Project Avary better understand your child's needs. Please answer honestly this will not impact your child's enrollment into the program
What is the relationship of the incarcerated family member(s) to the child? *
Check all that apply.
Is this family member currently incarcerated in a State or Federal prison, or a County jail? Please choose all that apply
If currently incarcerated, where are they incarcerated and when will they be released? If recently released, when?
Your answer
Does the child have contact with the incarcerated family member?
If yes, What is the nature of the contact? Select all that apply
Has the child ever witnessed the arrest of the incarcerated family member?
If yes, please explain?
Your answer
Maturity and Behavior
Has the child gone on sleepovers (with family or friends)? *
Required
Has the child ever been to a camp? *
Required
If you checked a box above please tell us about their experience.
Your answer
How much ADULT supervision does this child need? Check all that apply... *
Required
Are there any particular behaviors where the child needs adult supervision? Check all that apply... *
Required
How does this child handle new environments/experiences/people? Please check all that apply. *
Required
How would you describe this child’s friendships? Lots of friends? Few friends? *
Your answer
In the past year has the child gotten into any physical fights with other children? *
Required
If yes, please explain.
Your answer
Has the child or sibling(s) ever run away from home? If so, for how many days? *
Your answer
How would you describe the child’s temperament? Check all that apply... *
Required
Has the child ever had any involvement with the Juvenile Justice System? Check all that apply... *
Required
Please explain boxes checked above.
Your answer
School Background
How is your child doing in school? *
Required
Please explain
Your answer
In the past year, has the child been suspended and/or expelled from school? Check all that apply... *
Has the child EVER been suspended and/or expelled from school? Check all that apply... *
Please explain boxes checked above.
Your answer
Support Network
Is this child currently involved in the Child Welfare System in any capacity? Check all that apply... *
Required
If so, in what county does the child receive services?
Your answer
What other adults are involved in this child’s life? Check all that apply... *
Required
Is there anything else you think we should know that will help us better serve this child or your family? *
Your answer
After the Intake is Complete by the Referring Party and Caregiver
Children who qualify will receive an Invite/Application, Family Health History and Doctor Approval Form. We can either send this Invite/Application to the referring party, or to the family directly.

After we receive the completed paperwork, we'll determine if we have a space for the child at camp, and for which session. If the child has summer school or other summer conflicts, the caregiver should note this on the application.

Once the child is accepted into the program, we mail a Enrollment Packet, which includes a Enrollment Agreement, a Packing List, Pick-up & Drop-off information, Welcome Surevey (to be filled out by child) and Avary Caregiver Survey (to be filled out by the caregiver).

IMPORTANT: To attend camp every child MUST make a doctor's appointment, and have the doctor fill out the doctor's form that comes in the registration packet. Since this is often the most challenging aspect of the process, we suggest making an appointment as soon as possible.

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