Registration Form (Program Participant/Mentee)

“I CAN DO IT!

YOU CAN DO IT!“

Participant Registration Form

Date: User ID:

Welcome!

1. Name: ________________________________________________________________________

2. Address: ___________________________________________________________

Address

___________________________________________________________

City State Zip Code

3. Parent/Guardian Contact Information:

	Mother	Father
Name:
Home Phone:
Work Phone:
Cell phone:
e-mail:

4. Emergency Contact: _________________________________________________________

Name

____________________________________________________

Address

____________________________________________________

City State Zip Code

5. Are You: ❏ Male ❏ Female

6. Are you Hispanic or Latino? ❏ Yes ❏ No

7. Which best describes your race?

❏ American Indian/Alaskan Native

❏ Asian or Pacific Islander

❏ Black/African-American

❏ White/Caucasian

8. How old are you?  _____________ years old

9. How many people 18 and older live in your house with you?  _____________

10. How many people 17 and younger live in your house with you?  _____________

11. What is the main language spoken in your home?

❏ English

❏ Spanish

❏ Other (describe): _____________________________________________

12. What is the highest grade or year of school either of your parent(s) completed? (please check one)

❏ Never attended school or only attended kindergarten

❏ Grades 1 through 8 (Elementary)

❏ Grades 9 through 11 (Some high school)

❏ Grade 12 or GED (High school graduate)

❏ College 1 year to 3 years (Some college or technical school)

❏ College 4 years or more (College graduate)

13. What is the total annual income earned by everyone in your household?

❏ Under $10,000

❏ Between $10,000 and $14,999

❏ Between $15,000 and $19,999

❏ Between $20,000 and $24,999

❏ Between $25,000 and $34,999

❏ Between $35,000 and $49,999

❏ Between $50,000 and $74,999

❏ $75,000 or more

14. What type of disability or health condition do you have? (please check all that apply):

❏ Cognitive Disability (e.g. Autism, Down’s Syndrome, Fragile X Syndrome)

❏ Learning Disability (e.g. Dyslexia, Attention Deficit Disorder, Sensory Integration Disorder)

❏ Mental Health Disability (e.g. Anxiety Disorder, Bipolar Disorder, Depression, Schizophrenia)

❏ Physical Disability (e.g. amputation, multiple chemical sensitivities, Muscular Dystrophy, Paraplegia, Cerebral Palsy, Spina Bifida)

❏ Sensory Disability (e.g. blindness or visual impairment, deaf or hard of hearing)

❏ Other (describe): ________________________________________________________________

15. Do you use any accommodations or special equipment?

❏ Yes (Please answer question 15A)

❏ No (Please skip to question 16)

15A. What types of accommodations and/or special equipment do you use? (Please check all that apply)

❏ Accommodations for Sensory Disabilities (ASL interpreter, alternate format materials, braille, captioning large print, scribe, reader, etc.)

❏ Accommodations for Mobility Impairments (walker, crutches, manual/motorized wheelchair, scooter, etc.)

❏ Assistive technology (describe): ____________________________________________________

❏ Personal Care Assistant

❏ Service animal (i.e. guide dog or other animal)

❏ Oxygen/special breathing equipment

❏ Other (describe):­­­­­­­­­­­­­­­­­­­­­­­________________________________________________________________

16. Do you have any allergies?

❏ Yes (Please answer question 16A)

❏ No (You're finished with the registration form!)

16A. Which allergies do you have? (Please check all that apply)

❏ Food allergies (describe): ___________________________________________

❏ Bee stings

❏ Other (describe): _____________________________________________

Thank you for completing this registration form.