Living Safely in Jackson Square Youth Organizing Application

Instructions: All fields marked “required” must be completed. Dates should all be typed in the format mm/dd/yyyy.

Participant Information

Date of Birth

Format MONTH/DATE/YEAR

Age

Address

City

State

Zip Code

Home Phone number

Cell Phone number (if available)

Gender

If you selected "Prefer to Self-Describe" please do so below.

Which of the following best describes you?

If you selected "Multiracial or Biracial" or "A race/ethnicity not listed here" please describe below.

Country of Birth

Are you currently enrolled in school?

What grade are you in?

What year did you graduate from high school?

If you selected "other" for grade, please provide more information below.

What high school did you attend?

What high school do you attend?

If you selected "other" or "METCO," please write in the name of your school below.

Parent/Guardian First and Last Name	Relationship to the Participant
Home Phone Number	Cell Phone Number
Parent/Guardian Email Address	Is the parent/guardian's address the same as the participant's address listed above? YesNo
Parent/Guardian Country of Birth	If you selected "other" please share more below.
Parent/Guardian Address: