Start with 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 If other describe:
*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 If other describe:
If you checked more than one box above, what is youth's primary disability?
*Are you able to use technology without accommodations? If not, what accommodations would make it possible for you to participate online?
Youth's Interest in PYD (ALT+I):
*How did you hear about Partners Online at Partners for Youth with Disabilities and why are you interested in participating?
*List specific topics/issues that you are interested in learning about.
*Do you have any areas of knowledge or resources you are interested in sharing with other youth?
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:
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.
