Skip to content

Careers
Online Shop
Cart

Programs & Training
Advocacy
- Reclaim Your Vote
Get Involved
Events
Who We Are
Donate

Apply to Participate

Participant Intake Form

Step 1 of 6

16%

URL

This field is for validation purposes and should be left unchanged.

Confidentiality Statement: All information contained in this form will be considered confidential information. Release of any information will require a signed “Consent to Release” form by the participant. If a referral is made on behalf of the participant, in signing the “Consent to Release” form, the participant is consenting to the information contained in this form to be released to the receiving agency.

Name(Required)

First Middle Last

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Age(Required)

Date of Birth(Required)

Parent/Guardian's Name

Relationship to Participant

Gender(Required)

Male

Female

Nonbinary

Prefer not to say

Other

Race/Ethnicity(Required)

Black

White

Asian

Hispanic

Pacific Islander

American Indian

Other

Your Email Address(Required)

Enter Email Confirm Email

Your Phone(Required)

What is your preferred method of contact?(Required)

Emergency Contact Information

Please provide the names and contact information for an adult or family member who we could contact if an emergency arises.

Contact 1 Name(Required)

Relationship to participant(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Contact 2 Name(Required)

Relationship to participant(Required)

Phone(Required)

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Education & Demographics

Are you currently in school?(Required)

Yes

No

If yes, list name of school:

Grade

What is the highest level of education that you have completed?(Required)

Less than High School (No Diploma received)

High School Diploma or GED

Some College credit (No degree completed)

Associate’s degree

Bachelor’s degree

Master’s degree

Are you interested in getting your GED?

Yes

No

Are you currently employed?(Required)

Yes

No

Actively looking

Do you currently have a child?(Required)

Yes

No

Currently expecting

Do you have a valid driver’s License?(Required)

Yes

No

Do you own an operating vehicle?(Required)

Yes

No

No, but I have reliable daily transportation

What is your current living situation?(Required)

Living alone

Parent(s) / Friend

Homeless and actively looking

Are you currently on parole or probation?(Required)

Yes

No

If on parole or probation, who is your Probation Officer?

Child(ren)

Name

Age

Please enter a number less than or equal to 17.

Does this child reside with you?

Name

Age

Please enter a number less than or equal to 17.

Does this child reside with you?

Name

Age

Please enter a number less than or equal to 17.

Does this child reside with you?

Name

Age

Please enter a number less than or equal to 17.

Does this child reside with you?

Name

Age

Please enter a number less than or equal to 17.

Does this child reside with you?

Is there anything else you’d like to share about your child(ren)?

Please answer the next three questions.

Please note again that all information you share with us is confidential.

Please list 2 short term goals (30-60 days).(Required)

Please list 2 long term goals (6 months to 1 year).(Required)

What are some areas you need assistance with?(Required)

Photography waiver(Required)

Please check the appropriate option:

Yes, you may take and use my photo or name in Springfield Urban League & Collaborative partner publications.

No, please do not take my photo or use my name in Springfield Urban League & Collaborative partner publications.

Consent(Required)

I give permission to the Springfield Urban League, Inc. and its designees to collect data, record data, receive any treatment by an accredited hospital and/or physician deemed necessary in case of an emergency. I understand all reasonable safety precautions will be taken at all times by the SUL staff and volunteers during events and activities. The data gathered is not restricted to the following:

Surveys and/or interviews about his/her knowledge, attitudes, skills, and behaviors in regard to his/her academic development, career aspirations, connection to the community, and overall satisfaction with the School-Age & Community Youth (S.A.Y.)/Workforce Development programs.

An academic assessment and school data releasing grade point average, report card, school attendance rate, and graduation information via District 186 Intranet (student/client cumulative folder).

SUL is pleased to provide programs and activities as part of its education and Youth/Workforce development programs. Participants in program and activities contingent upon the participant’s appropriate moral and ethical behavior. Any Participant not conducting himself/herself in this manner at any program or activity will be required to leave the program or activities at the expense of the parent when so informed by the event leaders in whose care the participant has been entrusted.

I understand that the purpose of this questionnaire and interview is to document the impact of the programs on its participants and to identify areas for improvement. I also understand that this information will remain private and that only the SUL staff will be able to look at his/her response.

My signature indicates that I fully understand this program guidelines described above, and the information I provided on this application/assessment is true and correct.

I consent to participation as outlined above.

Signature

Your Name
Your Name
Your Name

Join us in creating positive change in the community.

Facebook
Instagram
X
LinkedIn

Privacy Policy

© 2026 Springfield Urban League • Built with GeneratePress