Language
English (US)
Spanish (Latin America)
EVYP Youth Membership Application
East Village Youth Program prepares Chicago youth to become first generation college graduates.
Youth Member Information
Name
*
First Name
Last Name
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Youth Cell Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
Birthdate
*
-
Month
-
Day
Year
Date
Gender
*
Female
Male
Non-binary / third gender
Prefer not to say
Ethnicity (choose all that apply)
*
American Indian or Alaska Native
Asian
Black or African American
Hispanic/Latinx
Native Hawaiian or Pacific Islander
White
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Family Information
Parent 1
*
First Name
Last Name
Main Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Language(s) Spoken
*
English
Spanish
Other
Education
*
No high school
Some high school
High school diploma
Some college
Associate's degree
Bachelor's degree
Graduate or professional degree
Occupation
*
ex. cashier
Employer / Company
*
Parent 2
First Name
Last Name
Main Phone Number
-
Area Code
Phone Number
Email
example@example.com
Language(s) Spoken
English
Spanish
Other
Occupation
ex. cashier
Employer / Company
Education
No high school
Some high school
High school diploma
Some college
Associate's degree
Bachelor's degree
Graduate or professional degree
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Household Information
Household Type
*
Single Parent / Female
Single Parent / Male
Two-parent
Independent Youth
Relative
Guardian
Household Size
*
ex. 4
Monthly Household Income
*
ex. $1,240
School Information
Name of Elementary School
*
ex. Carl von Linne
School Type
CPS
Charter
Private
Homeschool
Name of High School
*
ex. Lane Tech
School Type
CPS
Charter
Private
Homeschool
Expected High School Graduation Year
*
ex. 2024
Emergency Contact
Emergency Contact
*
First Name
Last Name
Main Phone Number
*
-
Area Code
Phone Number
Email
example@example.com
Relationship to Member
*
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Program Enrollment / Family Involvement
Programs you would like to enroll in (check all that apply)
*
Tutoring Monday (5th-12th grade)
Tutoring Thursday (5th-12th grade)
Leadership Track (9th-10th grade)
Junior Year (11th grade)
Senior Year (12th grade)
College Success (college students)
How EVYP can best support you and your family (check all that apply)
College Workshops
Financial Aid Workshops
Immigration Services
Workforce Development
ESL Classes
Mental Health Services
Financial Literacy
Computer Classes
Other
How your family would like to be involved (check all that apply)
Parent Council
Fundraising
Event Planning
Administrative Support
Other
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Release of Personal Information
By checking the box below, I hereby certify that I am willing to provide all of the personal information asked for in this application as well as personal records. I understand that this information will be kept confidential and will be used for internal organizational purposes and not shared with any third parties.
Release of Personal Information
*
Yes
Submit
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