TSG Program Intake Form

THE SUPPORT GROUP PROGRAM INTAKE FORM
Program Interest*

Summer EmploymentMaximum Exposure: College & Career PathwaysSports InitiativesYouth Peace Ambassadors in MotionOther
Please choose what site/program you are registered at.*

TSG BBALL @ ACCATSG BBALL @ Kelvyn ParkTSG BBALL @ CVCATSG BBALL @ BeasleyTSG BBALL @ MatherTSG BBALL @ WellsTSG BBALL @ UpliftTSG BBALL @ RichardsTSG BBALL @ DunbarTSG BBALL @ Little VillageTSG YPAMBiz Boot Camp
Name*

First NameLast Name
Birthday*

MonthDayYear
Today

MonthDayYear
Age - days
Age - Years
Ethnicity/Race*

Non-HispanicBlackAsianWhiteNative Hawaiian or Other Pacific IslanderNative Indian/Alaksan DescentHispanicOther
Gender*

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

Area CodePhone Number
Phone Number #2

Area CodePhone Number
What is your plan after HS?*

4 Year College2 Year Program/CertificateMilitaryWorkUndecided
What area do you need extra support in?*

Academic/TutoringCollege ChoiceFinancial LiteracyCollege/Job ReadinessCreating Plan
Expected Graduation Year*
Please upload Consent forms

Browse Files

Cancelof
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PARENT INFORMATION
Family Type*
Name*

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

Area CodePhone 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