Services Intake Form Last 4 SS# Name * First Name Last Name Date of Birth * MM DD YYYY Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Parent or Guardian of Student First Name Last Name Address of Parent of Guardian of Student (if different than above) Address 1 Address 2 City State/Province Zip/Postal Code Country Sex Male Female Nonbinary Transgender GenderQueer Cisgender Race AFRICAN AMERICAN ASIAN HISPANIC OTHER WHITE Household Income Below $9,999 $10,000-$19,000 $20,000-$29,000 $30,000 and Up Are you employed? Yes No If yes, part-time or full-time? Part-Time Full-Time Do you have a diploma or GED? Yes No Highest Grade Completed Emergency Contact Information First Name Last Name Telephone Number * (###) ### #### Services Requested Employment Childcare GED COVID Relief Tutoring Food Pantry Parenting Classes Visitation After School Programs If interested in after school programs, please list your interest below Are you in school? Yes No Name of School Are you in any sports/activities after school other than Urban League? Yes No Sport/Activity (Date & Semester) Career Goals Are you planning to attend college? Yes No Undecided Intended Major Name of College (if known) FOR TSTM, TOPS, and Clubs ONLY To participate in TSTM/TOPS/Club programs we need access to grades, transcripts, and permission to release photos. Do you give your child permission to participate in the Tri-County (Peoria) Urban League's TSTM Program, and understand that parents/guardians are encouraged to attend TSTM Parent Group Meetings? Yes No Housing Are you worried or concerned that in the next two months you may not have stable housing that you own, rent or stay in as part of a household? Yes No Food Within the past 12 months, you worried that your food would run out before you got money to buy more? Yes No Transportation Do you put off or neglect going to the doctor because of distance or transportation? Yes No Utilities In the past 12 months has the electric, gas, oil or water company threatened to shut off service in your home? Yes No Child Care Do problems getting child care make it difficult for you to work and study? Yes No Finances Do problems getting child care make it difficult for you to work and study? Yes No Personal Safety Do you feel safe in your home? Yes No Assistance Would you like help with any of these needs? Yes No Thank you!
