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I'RAISE Girls & Boys International Corporation Virtual Youth Services Application
Section I
Our Virtual Activity services provides opportunities for children to stay occupied while at home during COVID-19. Children are able to acquire new skills and meet new friends. Each of our virtual activities are conducted by one of our experienced faciliatator/specialist.
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* Indicates required question
Child First and Last Name
*
Your answer
Child DOB
*
MM
/
DD
/
YYYY
Child Gender
*
Female
Male
Prefer not to say
Other:
Child Home Address
*
Street Number, Borough, Zip Code, State
Your answer
Which best describes the race/ethnicty of your child?
*
African American/Black
Latin American/Hispanic
Caucasian/White
Bi-Racial
Middle Eastern
Indian
South East Asian
Asian
American Indian
Other
Required
School Child Attends
*
Your answer
Grade Child is in?
*
Your answer
Does any of the following apply to your child:
*
My child has individualized education plan
My child has developmental delay/s
My child has mental health diagnosis'
None of the above
Other:
Required
Parent/Gaurdian Name (First and last name)
*
Your answer
What is your relationship to the child.
*
Biological Mother
Biological Father
Grandparent
Aunt/Uncle
Step Parent
Foster Parent
Foster Parent (Kinship)
Other:
Parent/Gaurdian Address (If same as child. please indicate "same as child" below)
*
Street Address, Zip Code, Borough, State
Your answer
Parent /Gaurdian Mobile Number
*
Your answer
Parent/Gaurdian Email Address
*
Your answer
Which best describes the race/ethnicty of the parent/gaurdian completing this form?
*
African American/Black
Latin American/Hispanic
Caucasian/White
Bi-Racial
Middle Eastern
Indian
South East Asian
Asian
American Indian
Other
Primary Language Spoken at Home
*
English
Spanish
Creole
French
Arabic
Bengoli
Other:
Do you currently receive any of the following benefits for yourself or your child/ren?
*
SNAP Benefits
WIC
SSI
Disability
Child Support
Medicaid
Medicare
Temporary Housing
Rent Subsidy
None of the above
Other:
Does child have access to Both an electronic device and wireless connection at home to connect to virtual sessions?
*
Yes
No
Unsure
Other:
Please select the virtual activity group you would like to enroll your child in:
*
Each session is one hour long. Please select as many as you are interested in enrolling your child in.
Yoga/Meditation Groups (Mondays 4:30pm EST) Ages 5-18 Years
Visual Art Groups (Tuesdays & Thursdays 5 pm EST) Ages 9-16 Years
Legos (Fridays, 6 pm & Saturday, 12 pm EST) Ages 9-12
Read Aloud and Story-Telling (Mondays, Wednesdays, Thursdays 5 pm EST) Ages 5-10
One on one online Tutoring
Zumba Class for Teens (Ages 13-19)
Dance Class (Contemporary, Ballet) (All ages)
KickBoxing (Ages 9-18)
Music (Singing, Song Writing) (Ages 12-19)
Cosmetology Classes for Teens (Thursdays and Saturdays 5pm-7pm)
Entreprenuer Academy (Ages 16-21)
Other:
Required
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