House of Teens Application Form

Student Name

Student ID #

Full Student Address

Date of Birth

Grade

Student's Email Address

Student's Phone Number

Parent/Guardian Name

Full Parent/Guardian Address

Parent/Guardian Home Phone

Parent/Guardian Work Phone

Parent/Guardian Cell Phone

With whom does the reporting student currently live most of the time?

Student’s race/ethnicity (information is used for statistical purposes only)

Is the student functioning below grade level in

Does the student speak English?

List the subject(s) the student is having difficulty with and/or should focus on.

How did the student hear about the House of Teens?

Why is the student interested in attending the House of Teens? Check all that apply.

I need a gym credit
I am interested in fitness
I am looking for something to do after school
I need a health credit
I want to learn about advocacy
Other

Student's Guidance Counselor

Does the student have a job?

Student can attend program on the following days:

Monday
Tuesday
Wednesday
Thursday
Friday

Number of members in household (include student)

Student is eligible for (information is used for statistical purposes only)

There is transportation from New Britain High School to the YWCA directly after school. Program runs until 6:00 p.m. and students must have their own form of transportation home. Please list any other programs and the days and times of the programs the registering youth will be participating in, such as sports or extracurricular activities, that meet after school which may affect their attendance in the House of Teens

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