Project Me Pathways Program Intake Application

Please answer every question you can. We use this information to understand what you hope to accomplish and what support may help. Fields marked * are required. Submitted information is kept confidential for enrollment and service planning.

Page 1 of 11

Page 1

SECTION A - Personal Information

1. Full Name: *

2. Preferred Name/Nickname: *

3. Date of Birth (MM/DD/YYYY): *

4. Pronouns: * Check all that apply.

He/Him She/Her They/Them Other:

5. Contact Phone: *

6. Email Address:

7. Current Address: *

City: *

State: *

Zip: *

8. Best Way to Contact You: * Check all that apply.

Phone Call Text Email Other:

Page 2

SECTION B - Emergency / Guardian Contact

9. Parent/Guardian (if applicable):

10. Relationship to You: *

11. Emergency Contact Name (if different): *

12. Emergency Contact Phone: *

Page 4

SECTION D - Program Interests

18. Which Project Me Pathway services are you interested in? (Select all that apply) * Check all that apply.

Mentorship & Social-Emotional Support (UPLIFT) Leadership & Peer Development (EVOLVE) Academic / Education Support Postsecondary / College Preparation Career Readiness & Workforce Training Creative Track Programs (e.g., music, media)

Page 5

SECTION E - Needs Assessment

19. What challenges are you currently facing that you’d like support with? *

20. What are your personal goals for the next 6-12 months? (e.g., school, work, independent living) *

21. What strengths or interests do you bring to this program? (e.g., writing, art, leadership, public speaking) *

Page 7

SECTION G - Code of Conduct & Participant Agreement

Page 8

SECTION H - Parental/Guardian Consent for Mentorship & School Records

36. Parent/Guardian Signature: (Type name)

Required if the participant is under 18.

37. Date:

PDF example: January 7, 2019

Page 9

SECTION I - Background Check Notification

38. Parent/Guardian Acknowledgement of Background Check Policy: * Check all that apply.

I acknowledge and understand that all mentors, staff, and board members have completed background checks.

39. Signature: (Type name) *

40. Date: *

PDF example: January 7, 2019

Page 10

SECTION J - Non-Discrimination Policy Acknowledgement

41. Participant Signature: *

42. Date: *

PDF example: January 7, 2019

43. Parent/Guardian Signature (if under 18):

44. Date:

PDF example: January 7, 2019

Page 11

SECTION K - Acknowledgement & Signatures

45. Participant (Youth) Signature: *

46. Date *

PDF example: January 7, 2019

47. Parent/Guardian Signature (if under 18):

48. Date:

PDF example: January 7, 2019

49. Probation Officer (if applicable):

50. Date:

PDF example: January 7, 2019

51. Case Worker / Program Staff (if applicable):

52. Date (if applicable):

PDF example: January 7, 2019

Project Me Pathways Program Intake Application

SECTION A - Personal Information

SECTION B - Emergency / Guardian Contact

SECTION C - Demographics & Background

SECTION D - Program Interests

SECTION E - Needs Assessment

SECTION F - Availability & Commitment

SECTION G - Code of Conduct & Participant Agreement

SECTION H - Parental/Guardian Consent for Mentorship & School Records

SECTION I - Background Check Notification

SECTION J - Non-Discrimination Policy Acknowledgement

SECTION K - Acknowledgement & Signatures