Name of Parents or Guardians

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent's or Guardian's phone numbers.

Please give primary and secondary numbers.

Does the teen primarily reside at this address?

If so, type "Yes" and if not, please put the teen's primary residence here.

Teen's Name

First Name

Last Name

Teen's D.O.B.

Teen's School and Grade

Emergency Contact

Who should we contact if you're not available?

What are your main goals or hopes for your teen in this program?

What strengths or talents do you see in your teen?

How would you describe your teen’s communication style (e.g., open, reserved, etc.)?

Describe the emotional and social atmosphere surrounding the teen.

How does your teen deal with social situations?

What challenges or areas of growth do you think your teen is currently facing?

What motivates your teen or sparks their interest?

How do you usually support your teen during challenging times?

Is there anything else you'd like me to know about your teen to better support them?

Ask your teen's coach three questions?

Thank you for taking the time to answer those questions.

I know it’s not always easy to open up, especially with someone you’ve met or only know about virtually or through a friend. So, I want to acknowledge the courage and vulnerability it took to share your thoughts about your teen. I’m excited to meet your teen in person and to embark on this journey together with the support of you and that of our cohort.