Teamwork Englewood Youth Program Intake Form

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Please complete the registration form. For questions or concerns contact Calvin at cmoore@teamworkenglewood.org.

Email *

Record my email address with my response

First Name *

Last Name *

Select program to join *

Civic Leadership: A program for youth, by youth addressing community concerns and providing safe spaces for youth. Stipend included. High school students only.

Englewood Peace League: Coed basketball skills training and league for middle school and high school.

Change One: A program for males ages 16-30 focused on building connection, personal development, education and career pathways.

Required

Home Address (Please include apt numbers and zip codes.) *

Parent/Guardian Name *

Emergency Contact. Please provide name & number. *

Participant Birthdate *

YYYY

Gender *

Female

Male

Non-binary

Choose not to identify

Race/Ethnicity *

American-Indian/Alaskan Native

Asian

Black/African American

Hispanic/Latino(a)/Latinx

Middle Eastern/North African

Multi-Racial

Native Hawaiian/Other Pacific

White

Choose not to identify

Required

Current Grade *

School *

CPS ID Number *

Disabled: If yes, please specify. *

Family Type *

Single Parent/Female

Single Parent/Male

Two-parent household

Youth in Care

Relative

Guardian

Housing Status *

Rent

Own

CHA resident/HCV

Homeless/Sheter

In Temporary Housing

Income Source *

Employment

Pension

TANF

Earnfare

Social Security

Unemployed

Other (SSI, Child Support, VA Benefits)

I certify that the above information is accurate. I give my permission for the above named to participate in this program and to follow all program requirements.

Please confirm by date of birth.

YYYY

Send me a copy of my responses.

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