Start by Choosing the Programs You Are Interested In (ALT+S):
*Select a program (choose ALL that apply):
Program Options
Access to Theatre Mentor Match Partners Online Young Entrepreneurs Project Youth in Preparation for Independence Making Healthy Connections Not sure which program to choose
Personal and Contact Information of Youth (ALT+P):
*Last name of youth:
*First name of youth:
*Home phone:
Cell phone/pager:
Email address:
*Street address (include floor and apt. #):
*City:
*State:
*Zip code:
*Race/ethnicity (Check ONE only):
Race:
American Indian/Alaska Native Asian Black/African-American Hispanic/Latino Native Hawaiian/Pacific Islander White/Caucasian Other
Other
*Date of birth (mm/dd/yy):
*Age:
*Gender of youth:
Male
Female
*Number of adults in household:
*Number of youth 18 and under in household:
*Highest grade youth COMPLETED:
*Primary language spoken at home:
*Household income range (check one only):
Household income
Below $10,000 $10,000-$25,000 $25,000-$50,000 $50,000-$75,000 Above $75,000
PYD Program History, if Applicable (ALT+H):
List all PYD programs you have participated in:
PYD participation
Program 1: Program 1 start date (mm/yy): Program 2: Program 2 start date (mm/yy): Program 3: Program 3 start date (mm/yy):
How many (if any) mentors has youth been matched with and how long did each match last?
Nature of Youth's Disability (ALT+D):
*What is the nature of youth's disability? (check ALL that apply):
Nature of disability
None Physical Blind/low vision Deaf/hard of hearing Deaf-blind Learning Cognitive Emotional Other
Other
If you checked more than one box above, what is youth's primary disability?
If applicable, describe youth's functional abilities and limitations. What accommodations are needed?
Youth's School Performance (ALT+E):
*Describe the youth's school performance:
For example: grade point average, favorite subjects, list of special education classes, description of individualized education plan, attendance record
Youth's Interest in PYD (ALT+I):
*Why is the youth interested in this PYD program?
*What is the family's reaction to the youth's interest in this program?
Youth's Parents/Legal Guardians (ALT+G):
Custody arrangement (Sole? Joint? Who is permitted to pick up youth after classes/events?)
*Last name of parent/guardian 1:
*First Name of parent/guardian 1:
*Relationship to youth:
*Home phone:
Work phone, cell phone or pager:
Email address:
Yes, address is the same as youth (skip following address if same as youth)
Street address (including apartment #)
City:
State:
Zip code:
Last name of parent/guardian 2:
First name of parent/guardian 2:
Relationship to youth:
Home phone:
Work phone, cell phone or pager:
Email address:
Yes, address is the same as youth (skip following address if same as above)
Street address (including apartment #)
City:
State:
Zip code:
Family/Household Members (ALT+F):
Family/household member 1:
Family/household member 1
Name:
Age:
Male
Female Type of job/school:
Relationship:
Family/household member 2:
Family/household member 2
Name:
Age:
Male
Female Type of job/school:
Relationship:
Family/household member 3:
Family/household member 3
Name:
Age:
Male
Female Type of job/school:
Relationship:
Family/household member 4:
Family/household member 4
Name:
Age:
Male
Female Type of job/school:
Relationship:
List additional household members:
Reference Information (ALT+R):
Name of person who referred youth to PYD:
Name of agency who referred youth to PYD:
Address of referral agency:
Phone number of referral agency:
List Agencies in Which the Youth is Involved (ALT+A):
Name of agency 1:
Agency 1
Name: Contact person: Phone: Purpose of involvement:
Name of agency 2:
Agency 2
Name: Contact person: Phone: Purpose of involvement:
Name of agency 3:
Agency 3
Name: Contact person: Phone: Purpose of involvement:
List additional agencies:
Medical Status (ALT+M):
*Please describe any of the youth's medical problems, allergies and restricted activities.
Has the youth received any mental health counseling? If so, please describe.
Does the youth take any medications for attention, mood or psychiatric issues (Example: Ritalin, lithium, Prozac)?
Other Relationships and Future Planning (ALT+O):
How are the youth's peer relationships? Does youth socialize primarily in school, in the community, in church, etc.?
What are the youth's educational and career plans?
What does the youth do for fun? Hobbies? Favorite recreational activities? Interests?
Does the youth have access to transportation? Please describe how youth generally travels.
Final Steps (ALT+Z):
*Did the applicant complete this form?
Yes, the applicant completed this form. No, someone other then the applicant completed this form.
If no, provide name:
Review the entire form and confirm that all of your answers are correct.
Print and file a copy of this application with your personal records.
