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Participant Intake Form
Please provide the following information for your teen who will be participating in Teen Social Club.
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* Indicates required question
Participant Last Name
*
Your answer
Participant First Name
*
Your answer
Participant Gender
*
Choose
Female
Male
Transgender
Non-binary/non-conforming.
Prefer not to respond.
Participant Age (in years)
*
This helps with planning each social club and matching participants with our volunteer buddies...
Your answer
Is the participant Hispanic, Latino, or of Spanish origin?
*
Yes
No
I decline to answer
How would you (participant) describe yourself?
Yes
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
Yes
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White
How often are you available to participate in Social Club? (check all that apply)
*
Monthly
Every other week
Weekly
Other:
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