Youth Prevention Application – NFR Family Wellness

CIF

Internal use only

Service Area *

Section 1 Student Information

Name *

First

Last

Mailing Address *

Address Line 1

Address Line 2

City

State

Zip Code

Physical Address *

Address Line 1

Address Line 2

City

State

Zip Code

Tribal Affiliation

School Attending

Age

Date of Birth

Parent/Guardian #1 Name *

First

Last

Parent/Guardian #2 Name *

First

Last

Phone *

Message Phone (if different) *

Section 2 Risk Factors for Services

Have you ever experimented with drugs? *

Yes
No

Have you ever been exposed to alcohol or drugs? *

Yes
No

How often are you exposed to alcohol or drugs? *

Daily
Other

If other, how often? *

Have you ever felt peer pressure to have sex? *

Yes
No

Are you sexually active? *

Yes
No

Have you ever been exposed to violence? (Physical or Verbal) *

Yes
No

Have you ever been in an altercation /fight? *

Yes
No

Have you ever been suspended from school? *

Yes
No

Have you ever been arrested? *

Yes
No

Do you live with your parents? *

Yes
No

Are your parents married? *

Yes
No

Do you currently have a “C” average (2.0 gpa)? *

Yes
No

Do you consider yourself a risk taker? *

Yes
No

Have you experienced the loss of a family member or friend? *

Yes
No

Do you live on the Rancheria? *

Yes
No

Do you feel safe in your community? *

Yes
No

In your opinion, do many kids in your community, under 18 yrs use alcohol and drugs? *

Yes
No

Section 3

Specify Activities that would interest you? *

I 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.

Signature *

Date *