General 1 — Corner House Site

Student Outreach Intake Form

Please fill out this form for the Advocacy for Youth Project, Princeton Youth Project, and World of Work for Youth programs.

If you have any questions regarding the application, please contact Denise Spivey at dspivey@cornerhousenj.org or Sam Nelson at snelson@cornerhousenj.org.

Outreach Program

Date

YYYY

Student's Name

First Name

Last Name

Birthdate

YYYY

Age

Gender

Ethnicity

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Cell Phone

(###)

###

####

Parent or Guardian Name(s)

Parent or Guardian's Address

Parent or Guardian's Home Phone

(###)

###

####

Parent or Guardian's Cell Phone

(###)

###

####

Parent or Guardian's Email

Emergency Contact

First Name

Last Name

Phone Number

(###)

###

####

Allergies

Name of School

Guidance Counselor

First Name

Last Name

Do you have any attendance and/or disciplinary issues?

If yes, please explain:

Who do you live with?

How many siblings do you have?

What is your home life/environment like?

Do you currently have a job?

If yes, where do you work, what do you do, and how long have you worked there?

How many hours per week do you work?

Do you need assistance finding a job?

Please list any legal charges or legal involvement:

Probation Officer

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone Number

(###)

###

####

Are you involved with any other Corner House programs?

If yes, please list:

Do you participate in any volunteer work?

If yes, please explain:

Please list any extracurricular activities (sports, clubs, etc.):

What days/times do you attend your extracurricular activities? (e.g. sports practices)

What are your hobbies?

Where do you see yourself 5 years from now

Is there anything in particular you would like to discuss or see happen this year in this group?

Student's Signature (Typed)

First Name

Last Name

Date

YYYY

Outreach Coordinator

Date

YYYY

“My mission in life is not merely to survive, but to THRIVE.”

— Maya Angelou