Intake Application – The Sankofa Project

First and Last Name of Parent/Guardian

Relationship to Youth

Phone Number

Able to receive text at the phone number provided?

Yes No

Address

City

State

Zip-Code

Employer

Work Phone

Information provided is grouped for fundraising and grant writing:

Number of people in primary household:

Range for annual primary household income:

Does child receive free or reduced lunch?

Yes No

First and Last Name of Adult Other Than Parent authorized to pick up child:

Phone Number

List anyone not allowed to pick up child by court order:

First and Last Name of Youth

Birthday

Gender

Grade

Cell #, if applicable

Race/Ethnicity

Current School

The questions below are designed to help us understand and work effectively with your child. You are not requested to answer these questions. However, the lack of this information may affect our ability to work with your child.

Describe any unusual health related conditions of the child

Does your child have any physical or mental disabilities, developmental delays, or emotional/behavior disorders that we should be aware of to help your child be successful in the Sankofa Rites Project?

Has your child experienced any emotional trauma?

Yes No

Is your child receiving any services through Special Education?

Yes No

How did you learn about The Sankofa Rites Project?

The Sankofa Project Standards & Procedures regarding how things will be handled in the event child is involved in a conflict or unsafe situation with another youth or staff or has violated the Standards and Procedures.

• Statement of Expectations: Rules and Consequences (Examples: Verbal redirection/coaching, Take a break space, Meeting with Program Coordinator and documentation of the incident, A call home and/or short-term suspension, A long-term suspension or termination of participation, Suspension/Termination of participation)

I have and read and understand the standards and procedures.

Permission and Release Form

Field Trip Transportation and Supervision Safety Authorization for Medical Care (in case of serious accident or illness) Media Consent Media Opt Out Consent to view PG and Explicit rated videos Consent for any kind of survey used for research purposes.

Name of Person giving permission

Relationship to Youth