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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?
With mother
With father
With grandparents
With friend
With other family members
In a residential facility
With guardian (not parent)
Other
Student’s race/ethnicity (information is used for statistical purposes only)
African - American or Black
Hispanic/Latin - American
Multi - racial, multi - ethnic
Asian, Asian - American
Caucasian, White
Other
Is the student functioning below grade level in
Reading
Math
Both
Neither
Don't know
Does the student speak English?
Yes
No
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?
Yes
No
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)
Free lunch
Reduced lunch
Neither
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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