Youth Application Changing my future SECTION ONE: GENERAL INFORMATION Name * First Name Last Name Preferred Name How did you hear about Why I Am? Primary Phone Number: * (###) ### #### May we text this number? Yes No Best or preferred contact method Phone Email Other: Date of Birth: * MM DD YYYY Gender/Identity Please check all that apply Male Female I identify as LGBTQ+ Other/not listed Prefer not to disclose Ethnicity Please check all that apply American Indian or Alaska Native Asian Black or African American Hispanic or Latino Native Hawaiian or Pacific Islander White Prefer not to disclose Other/not listed SECTION TWO: I can commit to a minimum of 2 hours every other week for the next year Yes No Best times to meet Weekdays Lunchtime After school (after 3pm) Evenings (after 5pm) Weekends Other 'other' as listed: What careers are you interested in? What is one goal you have set for the future? What is one new thing you're interested in learning? Please share if you speak languages other than English: If you had a whole day to do whatever you want, what would you do? These words describe me check all that apply Quiet Talkative Shy Friendly Adventurous Helpful Moody Happy Sad Lonely Outgoing Popular Cautious Loud Serious Active Hopeful Other words I use to describe myself are: Favorite quote, scripture or encouraging word * *Why I Am conducts background checks through state and federal agencies for criminal records, child abuse and neglect proceedings Who or what is your favorite Music group? Who is your favorite Famous person? What is your favorite Book or story? What is your favorite school subject? What is your favorite physical activity? What is your favorite food? What is your favorite movie or show? What is your favorite video or computer game? What is your favorite place to hang out? What is your favorite time of the year? One thing you hate Anything else you hate List two things you do well What qualities do you value in an adult? What do you hope to learn from your mentor? Rate your level or interest or knowledge in the areas below Strongly Disagree is the lowest/least and Strongly Agree is the highest/more experienced Faith Strongly Disagree Disagree Neutral Agree Strongly Agree Outdoor activities Strongly Disagree Disagree Neutral Agree Strongly Agree Academics Strongly Disagree Disagree Neutral Agree Strongly Agree Athletics Strongly Disagree Disagree Neutral Agree Strongly Agree Life Skills (finances/independent living) Strongly Disagree Disagree Neutral Agree Strongly Agree Technology Strongly Disagree Disagree Neutral Agree Strongly Agree Mechanical Strongly Disagree Disagree Neutral Agree Strongly Agree Social Skills/Relationships Strongly Disagree Disagree Neutral Agree Strongly Agree Health/wellness Strongly Disagree Disagree Neutral Agree Strongly Agree Music/Production Strongly Disagree Disagree Neutral Agree Strongly Agree Thank you!
