Culikid General Intake Form
Thank you for your interest in attending a Culikid program! Please fill out this form to help us get to know the potential participant and ensure their fit with their desired program before they join. After we receive this form, we may follow up to schedule a virtual intake with the participant and guardian.

On this page, we'll gather some general information about the potential participant. Then, we'll ask which program or programs you're interested in joining, and in the last section, we'll ask for some more detailed information about the participant's strengths and goals.

After submitting the form, you will be contacted by a member of our team to discuss next steps. If you have any questions in the meantime, please contact us at info@culikid.org.

If you think you've already filled out this form and are interested in joining a new program, email us at info@culikid.org and we will let you know what (if any) supplemental information we need.
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Participant's name: *
Participant's pronouns: *
Participant's birthdate: *
Make sure to include their birth year and not the current year.
MM
/
DD
/
YYYY
Participant's full home address: *
If the participant communicates independently, what is the participant's email address?
If the participant attends school, what school do they attend? *
What is the participant's first language? *
Does the participant have any food allergies or dietary restrictions? If so, please share. *
Does the participant have any other food aversions? If so, please share.
Participant's race & ethnicity:
Culikid's programming is open to everyone, regardless of race, ethnicity, or other demographic factors. We are asking this question ONLY to report to funders who ask for this information. Responding to this question is optional. You may select as many as apply. These categories were taken from the race and ethnicity questions of the US Census.
Guardian's name: *
This will be the person we contact for more information about registering as well as the emergency contact for the participant. If this should be different people, please add the main contact here and note the emergency contact in the very last question of page 3 of this form.
Guardian's email address: *
Guardian's phone number: *
Relationship to the participant: *
How did you hear about Culikid? *
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