YOUTH INTAKE FORM

Please direct any questions to:
Email: info@multiculturalfamilies.org
Phone: 253.216.4479

Which Program are you registering for?

CONTACT INFORMATION

Client ID

First Name

Middle Initial

Last Name

Preferred Name:

Preferred Phone:

Phone

Preferred Email

Emergency contact name

Emergency contact phone

Relationship to youth

ADDRESS INFORMATION

Mailing Address:

Mailing City:

Mailing State

Mailing Zip

Housing Status

DEMOGRAPHIC INFORMATION

Date of Birth

Gender

Sexual Orientation

Ethnicity

Country of Origin

Race

Other Race Subcategory

Grade Level

School

Other School

Expected graduation date

Primary Language

Other Primary Language

Do you need an interpreter

Secondary Language

Other secondary language

Do you have a disability?

YesNo

What is/are your disability/disabilities?

Please list any current allergies you may have

INCOME INFORMATION

Using the chart above, what is your household income category?

Number of household members

Free/Reduced Lunch

YesNo

Parent Information

Parent First Name

Parent Last Name

Parent Email

Parent Phone

Preferred method of contact

MEDIA RELEASE

I hereby give my permission for ODMF to use my child’s photograph/image in its various marketing publications or other media.

I agree

YesNo

Date

Participant Signature

Contact Information