RHTWG — Participant Intake Form

Participant intake has been recorded successfully.

Intake Information

Intake Date *

Site Location *

Track(s) Enrolling In *

How did you hear about RHTWG? *

Participant Information

First Name *

Last Name *

Date of Birth *

Phone Number

Email Address

Optional

ZIP Code *

Required for grant reporting

City

Demographics (Required for Grant Reporting)

Collected to fulfill grant reporting requirements. All data is kept confidential.

Gender Identity *

Race / Ethnicity *

Veteran Status *

Yes - currently serving Yes - veteran No Prefer not to answer

Current Situation

Current Housing Status *

Employment Status

Emergency Contact

Emergency Contact Name

Relationship

EC Phone

Consent

Parent/Guardian Consent: I am the parent or legal guardian of this minor and consent to their participation in RHTWG Teen programming. *

Staff Information

Staff PIN *

Your personal 4-digit staff ID — do not share

Notes

Data is sent securely to the RHTWG intake spreadsheet.

RISE HEAL THRIVE WELLNESS GROUP