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ENRICH
ENROLLMENT
Step
1
of
6
16%
Personal Information
Student Name
(Required)
First
Last
Date of birth
(Required)
MM slash DD slash YYYY
Age
(Required)
Is student under or over 18?
(Required)
Under 18
Over 18
Gender
Female
Male
Is the youth a parent?
(Required)
Yes
No
Is the youth employed or in secondary education? (for students 18+)
(Required)
Yes
No
Is the youth incarcerated?
(Required)
Yes
No
Is the youth on track to graduate HS? (if student is in HS)
(Required)
Yes
No
Is the youth pregnant?
(Required)
Yes
No
Is the youth homeless?
(Required)
Yes
No
Current living situation
(Required)
Foster Home
Group Home
Transitional Home
Other
If other, please specify
(Required)
Group Home Name
(Required)
Address
(Required)
Street Address
Address Line 2
City
State / Province / Region
ZIP / Postal Code
Contact Information (Over 18)
Youth Phone Number
(Required)
Youth Email
(Required)
Emergency Contact
(Required)
First
Last
Emergency Contact Phone
(Required)
Contact Information (Under 18)
Student Phone Number (if Applicable)
(Required)
Student Email (If Applicable)
(Required)
Caregiver Name
(Required)
First
Last
Caregiver Phone Number
(Required)
Caregiver Email
(Required)
Case Manager Information/Child Welfare Team
Case Management Agency/Community Base Agency
(Required)
Case Manager Name
(Required)
First
Last
Case Manager Email
(Required)
Case Manager Phone
(Required)
Please include the name, phone number and email of any other child welfare team members to be included in collaboration & communication.
Interests and Hobbies
To help us design experiences and support that matches your interests, please select your top interests and hobbies:
What types of activities are you most interested in? (Select all that apply)
(Required)
Arts & Crafts
Music & Singing
Dance & Performing Arts
Sports & Athletics
Science & Technology
Reading & Writing
Outdoor Activities (e.g., hiking, camping)
Gaming & Board Games
Community Service & Volunteering
Cooking & Baking
Other
If other, please specify
(Required)
Have you participated in any activities like these before?
(Required)
Yes
No
Is there something new you would like to try?
(Required)
Celebrations
We love to celebrate important milestones! Please help us learn how we can celebrate with you.
Would you like us to help celebrate your birthday?
(Required)
Yes
No
Are there any other special achievements or milestones you'd like us to celebrate (e.g., graduation, sports accomplishments, personal milestones)?
(Required)
Safe Spaces
We want to ensure you have the resources you need. Please indicate if any of the following items would be helpful for you:
What resources would you find useful in your home or living space? (Select all that apply)
(Required)
Hygiene Products
Baby Products
Clothing
School Supplies
Activity Kits (e.g., movie night, game night)
Other
If other, please specify
(Required)
Is there anything else you’d like to share with us about your interests, needs, or things you'd like to experience in the Enrich program?
(Required)
Consent to Services
Consent
(Required)
I agree to participate in the Enrich program and understand that my information will be used to help tailor activities and resources to my needs. I consent to being contacted regarding Enrich program activities and events. I understand that my photos and stories may be shared with the program for celebration purposes.
Signature
(Required)
