Forms - Youth Services Intake

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Youth Services Intake - Welcome

First Name (required)

Last Name (required)

Phone Number (required)

Email (required)

I am available to participate in classes on the following day(s). Check all that apply. (required)

Select All

Demographic Information

Please check this box if you are older than 18? (required)

Date Of Birth (required)

Gender (required)

Ethnicity (required)

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Race (required)

Select All

Primary Language (required)

Address Line 1 (required)

Address Line 2 (required)

City (required)

State (required)

Zip Code (required)

Contact Information

Parent/Guardian Information:

Name of Parent/Guardian (required)

Parent/Guardian Phone Number (required)

Parent/Guardian Email (required)

Alternate Contact Information:

Alternate Contact Name (required)

Relationship/connection to you: (required)

Alternate contact Phone Number (required)

Alternate Contact Email Address (required)

Education and Support Information

School Status Or Name Of School (required)

School Grade (required)

Are you eligible for any of these services? (required)

Select All

How did you hear about our programs? (required)

Is there anything else you would like to share with us? (required)

Thank you for registering for the Bethany/GRCCT Youth Services Programming. Contact us with any questions at 616-254-7736 or email youthservices@bethany.org We look forwar to connecting with you soon!

Address Line 3 (required)

Age (required)

Are either of your parents/guardians currently incarcerated? (required)

Are there any specific accessibility needs our staff should be aware of? (required)

Are you considered to have refugee status/seeking asylum in the U.S.? (required)

Are you currently or have you ever been placed in foster care? (required)

Country (required)

County (required)

Do you have any children or currently expecting a child? (required)

Do you have any history with juvenile or criminal justice departments? (required)

Do you receive any treatment for your mental health? (required)

Have you ever experienced homelessness? (required)

If you are attending school, what is the name of the school? (required)

If you know to which program you are signing up for, please write that here. The choices are Love Notes, Making Proud Choices, or Saddle Up for Success (required)

Location (required)

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Which best describes your current housing arrangement: (required)

You are currently in Middle School or High School? (required)

Status Reason (required)

Status Reason Details (required)

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