ProTrek Intake Form

We are excited for you to join us at the GRCCT!

Please have yourself or your guardian complete the following form as fully as possible to register for the next cohort.

I am available after school on these days (Check all that apply):

Monday *

Yes

No

Tuesday *

Yes

No

Wednesday *

Yes

No

Thursday *

Yes

No

Location of Classes: *

I'm interested in Finding a Mentor *

True

False

First Name *

Last Name *

Demographic Information

Today's Date: * +

Date of Birth * +

Gender Identity

Female *

True

False

Male *

True

False

Non-Binary *

True

False

Preferred Pronoun

He/Him *

True

False

She/Her *

True

False

They/Them *

True

False

Racial/Ethnic Identity - check all that apply

Asian/Pacific Islander *

True

False

Black/African American *

True

False

Hispanic or Latino/a/x *

True

False

Native American *

True

False

White/Caucasian *

True

False

Other Racial/Ethnic Identity?

Contact Information

Street Address *

City *

State *

Zip/Postal Code *

Phone Number *

Email Address

Preferred method of contact: *

Other Contact Method

Parent/Guardian Information:

Name of Parent/Guardian

Parent/Guardian Phone Number

Parent/Guardian Email

Alternate Contact Information:

Alternate Contact Name

Relationship/connection to you:

Alternate contact Phone Number

Alternate Contact Email Address

Which best describes your current housing arrangement: *

Education and Support Information

Are you currently in Middle School or High School? *

True

False

If you are attending school, what is the name of the school?

Current Grade Level *

If other, what is the name of the school?

Are you currently or have you ever been placed in foster care? *

True

False

Are there any specific accessibility needs our staff should be aware of? *

True

False

Are you considered to have refugee status/seeking asylum in the U.S.? *

True

False

Do you have any history with juvenile or criminal justice departments? *

True

False

Have you ever experienced homelessness? *

True

False

Do you receive any treatment for your mental health? *

True

False

Do you have any children or currently expecting a child? *

True

False

Are either of your parents/guardians currently incarcerated? *

True

False

Parents' Marital Status *

Are you eligible for any of these services? (Check all that apply)

Food Assistance? *

Supplemental Security Income *

Cash Assistance *

Section 8 Housing *

Medicaid *

How did you hear about our programs? *

Anything else you want us to know?

Thank you for registering for the GRCCT ProTrek programming. Contact us with any questions at 616-254-7736 or email youthservices@bethany.org

We look forward to connecting with you soon!