Please enable JavaScript in your browser to complete this form.Youth Prevention ApplicationSection I - Student InformationName: *FirstLastPhysical Address: *(address, city, state, zip)Mailing Address:(address, city, state, zip)Age: *Birthdate: *Gender:MaleFeMaleOtherSchool Attending: *Grade: *T-KKindergarten1st Grade2nd Grade3rd Grade4th Grade5th Grade6th Grade7th Grade8th Grade9th Grade10th Grade11th Grade12th GradeTribal Affiliation:Parent/Guardian Full Name: *Phone: *Message Phone (if different)Section II - Risk Factors for ServicesHave you ever experimented with drugs? *YesNoHave you ever been exposed to alcohol or drugs? *YesNoHow often are you exposed to alcohol or drugs? *DailyOtherIf other, how often? *Have you ever felt peer pressure to have sex? *YesNoAre you sexually active? *YesNoHave you ever been exposed to violence? (Physical or Verbal) *YesNoHave you ever been in an altercation / fight? *YesNoHave you ever been suspended from school? *YesNoHave you ever been arrested? *YesNoDo you live with your parents? *YesNoAre your parents married? *YesNoDo you currently have a "C" average (2.0 gpa)? *YesNoDo you consider yourself a risk taker? *YesNoHave you experienced the loss of a family member or friend? *YesNoDo you live on the Rancheria? *YesNoDo you feel safe in your community? *YesNoIn your opinion, do many kids in your community, under 18 yrs use alcohol and drugs? *YesNoSection III - Specify Activities that would interest you?Terms and Services *I agreeI certify that all information reported in this application is accurate to the best of my knowledge and hereby authorize the information to be used by North Fork Rancheria Tribal TANF Program, for the purpose of Data Tracking. Disclaimer: I understand that my information is confidential and will not be divulged to anyone, including my parents.Name *FirstLastSubmit
