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Youth Interest Survey
1. Who Are You?
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1
. Who are you and what is your contact information?
Who are you and what is your contact information?
First & Last Name:
Mailing Address:
City & Zip:
Home Phone #:
Cell Phone #:
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2
. What grade are you in currently?
What grade are you in currently?
7th Grade
8th Grade
9th Grade (Freshman)
10th Grade (Sophomore)
11th Grade (Junior)
12th Grade (Senior)
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3
. Male / Female
Male / Female
Male
Female
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4
. What High School or Middle School do you attend?
What High School or Middle School do you attend?
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5
. Everyone has a different family make-up. Which best describes your family?
Everyone has a different family make-up. Which best describes your family?
Two Parent Family - Both birth parents
Blended Family - Stepfamily
Single Parent Family - live with Mom
Single Parent Family - live with Dad
Live with Grandparents
Foster Family
Other (please specify)
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6
. Important Information!
MM
DD
YYYY
When is your birthday?
Important Information! When is your birthday? Month
/
Day
/
Year
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