Youth Inquiry Form

Non-Discrimination Policy

Our participants come to us with a wide range of personal characteristics. We believe that participant eligibility shall be determined without regard to race, color, religion, national origin, gender, marital status, sexual orientation, gender identity, veteran status, or disability.

Program Interest

Which Program are you interested in?

Community-BasedSchool-BasedCHARGED (Small-Group Mentoring for High School Students)Undecided

Youth Information

First Name

Last Name

Preferred Name

Birthdate

Gender	Personal Pronouns
How does the youth identify?	What pronouns does the youth use?
School	Graduation Year from High School This is the year the youth will graduate.

School Account ID

Mobile Phone (High School CHARGED Students ONLY)

Personal Email Address (High School CHARGED Students ONLY)

Race/Ethnicity

American Indian or Alaska NativeAsian IndianBlack or African AmericanChamorroChineseFilipinoHispanic - CubanHispanic-Mexican,MexicanAmerican,ChicanoHispanic-Other Latinx or Spanish originHispanic - Puerto RicanJapaneseKoreanMiddle Eastern or North AfricanNative HawaiianOtherOther AsianOther Pacific IslanderPrefer not to saySamoanSome other race or originVietnameseWhite or Caucasian

Parent/Guardian Information

Guardian's Relationship to Youth

The parent/guardian is this child's

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Mobile Phone

Parent/Guardian Personal Email

I (Parent/Guardian) prefer to be contacted by

Family Information

Mailing Street Address

Mailing City

Mailing State

Mailing Zip Code

County

If you have any issues submitting your inquiry please contact us:

Email: allison@foundationforyouth.com

Call or Text: 765.558.1317

We will get back with you as soon as possible.

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Contact Information