The Youth Connection's SFP 10-14 Family Registration Form

Interested in your family participating in The Youth Connection's Virtual Strengthening Families Program: For Parents & Youth 10-14? Please fill out the form below!

NOTE: The information below is required to be in the SFP 10-14 program and your info will not be shared.

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* 1. Parent/Caregiver Full Name

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* 2. Home Address (Include city, state and zip code)

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* 3. Phone Number

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* 4. Parent/Caregiver's Age

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* 5. Parent/Caregiver's Date of Birth (ex 9.14.1971)

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* 6. Parent/Caregiver's Gender

Male

Female

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* 7. Parent/Caregiver's Race

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* 8. Email Address

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* 9. Are you living in any apartments of the Detroit Housing Commission (DHC)?

Yes

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* 10. If Yes, please select the DHC apartment you currently living in?

Brewster Homes

Charles Terrace/ Sojourner Truth

Diggs / Forest Park Place

Harriet Tubman Apartments

Riverbend Towers

Sheridan Place I & II

Smith Homes

State Fair Apartments

Villages at Parkside

Warren West Apartments

Woodbridge Senior Village

Other (please specify)

Please fill out the information below for ALL CHILDREN living in household (including ages 14 and under).

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* 11. Are you expecting?

Yes

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* 12. How many children do you have?

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* 13. Children(s) Name(s) (all children in household including ages 14 and under)

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* 14. Children (s) Date of Birth(s) (ex 9.14.1971)

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* 15. Children (s) Age(s)

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* 16. Male(s) or Female(s)

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* 17. Children(s) Race(s)

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* 18. Do you or your children have any food allergies?

Yes

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* 19. If yes to question 11, please list them:

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* 20. Participating in this program will require to come to our office to pick up supplies and materials needed for youth and parent/family sessions. Do you have transportation or someone to come pick up supplies for you?

Yes

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* 21. Do you have access to a electronic device (computer, phone, tablet, etc) with a webcam?

Yes

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* 22. Do you have internet access?

Yes

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* 23. How do you access the internet?

WIFI

Hotspot

Other (please specify)

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* 24. How did you hear about our Virtual SFP 10-14 program?

Social Media (Facebook, Instagram, etc.)

Website

Family Member/Friend

Event

Other (please specify)