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Youth Programs Intake
Filling out this form helps BICAS fund its youth programs by giving us valuable data to apply for grants. All demographic information is kept 100% anonymous when shared with entities outside of BICAS for funding and reporting purposes.
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* Indicates required question
First Name
*
Your answer
Nickname/Preferred Name (if different from above)
Your answer
Last Name
*
Your answer
Zip Code
*
Your answer
Birthday
*
MM
/
DD
/
YYYY
Parent or Guardian Name (skip for online classes)
Your answer
Parent or Guardian Phone Number (skip for online classes)
Your answer
Do you have any known allergies &/or health conditions? (Skip for online classes)
Peanut Allergy
Milk/Dairy Allergy
Eggs Allergy
Tree Nuts Allergy
Wheat Allergy
Soy Allergy
Penicillin Allergy
Asthma
Epilepsy/Seizure Disorder
Juvenile Diabetes
None
Other:
Will you need to take any prescription medication while you are at BICAS? If yes, please tell a BICAS staff member now. (skip for online classes)
Your answer
Are you currently enrolled in school?
*
Yes
No
Home Schooled
If no, what keeps you from going to school? (Skip if you are in school or are just on summer break.)
No transportation.
No one makes me go.
School is boring.
I get picked on at school.
I feel invisible at school.
I'm afraid of violence at school.
I need to work instead.
I have to take care of family members.
I already graduated.
Other:
Do you qualify for free or reduced lunch when in school?
Yes
No
Don't know
Clear selection
Do you currently have a job?
*
Yes
No
Unpaid/volunteer position
Gender (optional - check as many as apply)
Female/Girl/Woman
Male/Boy/Man
Non binary
Transgender
Two Spirit
Cisgender (not trans)
Decline to answer
Other:
Race/Ethnicity (optional - check as many as apply)
American Indian/Alaskan Native/Indigenous/First Nations
Native Hawaiian/Pacific Islander
Black/African/African American
Middle Eastern/North African
Latino/Latinx/Hispanic/Mexican/Chicanx
Asian
White
Decline to answer
Other:
I have read and I understand the BICAS Community Agreements. I agree to follow them. (skip for online classes)
Yes
No (If you say no, you will be asked to leave BICAS until you can agree to our Community Agreements.)
Clear selection
What BICAS program are you participating in?
*
Youth Drop In - Work Trade / Community Service
Youth Drop In - Working on my own bike
Work Trade
Court-ordered community service
Other community service/volunteering
Youth Earn-a-Bike Class
*Virtual* Youth Earn-a-Bike Class
Other:
FOR STAFF: Which program will the youth be participating in today? (skip if online class)
Youth Drop In - YLINC
Single-day project
Working on own bike
Class
Other:
Clear selection
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