TSG Program Intake Form

THE SUPPORT GROUP PROGRAM INTAKE FORM
Program Interest *

Summer Employment Maximum Exposure: College & Career Pathways Sports Initiatives Youth Peace Ambassadors in Motion
Please choose what site/program you are registered at. *

TSG BBALL @ ACCA TSG BBALL @ Kelvyn Park TSG BBALL @ CVCA TSG BBALL @ Beasley TSG BBALL @ Mather TSG BBALL @ Wells TSG BBALL @ Uplift TSG BBALL @ Richards TSG BBALL @ Dunbar TSG BBALL @ Little Village TSG YPAM Biz Boot Camp
Name *

First Name Last Name
Birthday *

Month Day Year
Today

Month Day Year
Age - days
Age - Years
Ethnicity/Race *

Non-Hispanic Black Asian White Native Hawaiian or Other Pacific Islander Native Indian/Alaksan Descent Hispanic
Gender *

Male Female
Name of School *
Grade *
GPA
SAT
ACT
NWEA
Email *
example@example.com
Phone Number #1 *

Area Code Phone Number
Phone Number #2

Area Code Phone Number
What is your plan after HS? *

4 Year College 2 Year Program/Certificate Military Work Undecided
What area do you need extra support in? *

Academic/Tutoring College Choice Financial Literacy College/Job Readiness Creating Plan
Expected Graduation Year *
Please upload Consent forms

Browse Files

Cancel of
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
PARENT INFORMATION
Family Type *
Name *

First Name Last Name
Parent Email *
example@example.com
Parent & Emergency Phone Number *

Area Code Phone Number
OTHER INFORMATION
WARD#
POLICE DISTRICT
IL STATE DISTRICT
US CONG DISTRICT
CONSENT
Parent Signature *

Clear
Print Name For Consent *
Initial for Consent *
Participant Signature *

Clear
Print Name for Consent *
Initial for Consent *
Should be Empty:

THE SUPPORT GROUP PROGRAM INTAKE FORM

PARENT INFORMATION

OTHER INFORMATION

CONSENT