Community Youth Development

Enrollment Form

Student Name *

Student Birthdate *

Student Grade

Ex: 9th

Student School

Ex: Abilene High School

Student Email *

Student Address *

Apt, suite, etc.

Country

City

State

Zip code

Student Gender

Student Race

Is this student Hispanic?

Yes

What is the primary language spoken at home?

Parent/Guardian Name *

Parent/Guardian Email *

Parent/Guardian Phone *

Has this student been on probation in the last 12 months? *

Yes

AUTHORIZATION FOR SERVICE

By signing below, I agree that I have been provided information on the referenced Prevention and Early Intervention Program and wish to receive services. I understand that data on my child/youth/family will be collected, maintained and entered in a secure database. The information will be utilized to track services for evaluation purposes and to ensure quality services are being provided. I hereby authorize my child/youth/family to participate in the program.

Signature *

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