DREAM Youth Enrollment Form (for paper upload ONLY)

First Name of Youth *

Last Name of Youth *

Nickname/Preferred Name

Date of Birth * +

Gender

Race/Ethnicity

Household Language(s)

Community Youth Lives In *

School Youth Attends

Current Grade in School *

Youth Home Phone Number *

Youth Personal Cell Phone Number

Youth Personal Email

Primary Street Address (with apartment number) *

City *

State *

Zip Code *

Receive free/reduced lunch at school?

Yes

No

Does your child participate in another mentoring program or other after-school groups?

Yes

No

If Yes, what program?

May DREAM reach out to a teacher of your child or other school personnel to support your child's schoolwork, mental and physical health, and/or wellbeing?

Yes

No

First and Last Name of Teacher or School Personnel

School Personnel Email Address and/or Phone Number

What DREAM program(s) is the family interested in?

Village Mentoring

Summer DREAM

Camp DREAM

Adventures Unlimited

Parent/Guardian Information (1)

First Name of Parent(s)/Guardian(s) (1) *

Last Name of Parent/Guardian (1) *

Relationship to Child (1) *

Primary Phone Number (1) *

Secondary Phone Number (1)

Parent/Guardian Email address (1)

Preferred Method of Contact (1)

Parent/Guardian Information (2)

First Name of Parent(s)/Guardian(s) (2)

Last Name of Parent Guardian (2)

Relationship to Child (2)

Primary Phone Number (2)

Secondary Phone Number (2)

Parent/Guardian Email Address (2)

Preferred Method of Contact (2)

Do you have rules for your child's behavior that you would like to be used during DREAM?

Emergency Contact Information (other than parent/guardian)

Person 1

First and Last Name *

Relationship to Youth *

Phone Number *

Is it okay to text Emergency Contact #1?

Person 2

First and Last Name (2)

Relationship to Youth

Phone Number

Is it okay to text Emergency Contact #2?

Person 3

First and Last Name (3)

Relationship to Youth

Phone Number

Is it okay to text Emergency Contact #3?

Emergency Contacts that can pick up, drop off, and/or accept youth:

	Yes	No
Emergency Contact #1	Yes	No
Emergency Contact #2	Yes	No
Emergency Contact #3	Yes	No

Additional People who can pick up, drop off, and/or accept youth from programming:

	Full Name	Relationship to Youth	Phone Number
#1:	Full Name	Relationship to Youth	Phone Number
#2:	Full Name	Relationship to Youth	Phone Number
#3:	Full Name	Relationship to Youth	Phone Number