VICTORY FOR YOUTH @ SLAM! MIAMI CHILD/YOUTH PARTICIPANT INFORMATION FORM

Child/Youth's Last Name *

Child/Youth's First Name *

Child/Youth's Middle Name

Date of Birth * +

Child/Youth Gender *

Street Address *

City *

Zip Code *

Caregiver Last Name *

Caregiver First Name *

Caregiver Phone Number *

Is this a cell/mobile phone? *

Yes

No

Caregiver Email Address *

Caregiver preferred language for contact (Please select only one): *

English

Spanish

Haitian Creole

(Optional) Youth Phone Number

(if provided) Is this a cell/mobile phone?

Yes

No

(Optional) Youth Email address *

Please note that The Children’s Trust may contact you via postal mail, email and/or text to ask about your satisfaction with services, and to make you aware of other Trust-funded programs, initiatives and events that may interest you.

What is the child/youth’s CURRENT grade level? (For summer, select the last grade completed - Please select only one): *

Miami-Dade County Public Schools ID # *

No M-DCPS ID #

ALL STUDENTS ATTENDING PUBLIC OR CHARTER SCHOOLS MUST HAVE A SCHOOL ID # ENTERED.

Child/Youth’s current school or college *

What is the child/youth’s preferred language for contact? (Please select only one) *

English

Spanish

Haitian Creole

What language(s) does the child/youth feel comfortable communicating in? (Select all that apply) *

Child/Youth Ethnicity Is the child/youth Hispanic or Latina/o/x? *

Yes

No

Is the child/youth Haitian? *

Yes

No

Child/Youth Race (Please select only one): *

We want to get to know your child better so that we can provide the best possible experience in our programs. Please tell us more about your child…

What are the main ways in which your child communicates? (Mark all that apply) *

Speaks and is easily understood	Speaks but is difficult to understand
Uses communication devices like pictures or a board	Uses gestures or expressions like pointing, pulling, smiling, frowning, or blinking
Uses sign language	Uses sounds that are not words like laughing, crying, or grunting

What, if any, help does your child/youth receive at this time? (Mark all that apply) *

What conditions does your child/youth have that are expected to last for a year or more? (Mark all that apply) *

If you marked “No condition lasting one year or more” on the previous question, please skip the next two questions and sign below. If you marked any other answer on the question above, please answer the remaining questions and sign below.

Do any of the conditions noted make it harder for your child/youth to do things that others of the same age can do? *

Yes

No

To support your child/youth’s successful participation in this program, in what areas might they need extra assistance? *

No specific help needed

Holding a crayon/pencil, writing, using scissors or other fine motor tasks

Sports or physical activities like running or other gross motor tasks

Managing feelings and behavior

Academic, learning or reading activities

Adapting activities to consider a visual or hearing impairment

Using assistive device(s) like a wheelchair, crutches, brace, or walker

Personal services like help with feeding, toileting, or changing clothes

Other Other

Please tell us anything else you think it is important for us to know about your child/youth:

If you are interested in other services funded by The Children’s Trust, please call 211 or visit www.thechildrenstrust.org. For special needs resources for your child/youth, visit www.advocacynetwork.org or www.thechildrenstrust.org/content/children-disabilities.

Acknowledgement *

As part of my child’s voluntary participation in this program, I give my permission for the information collected through this program to be submitted to The Children's Trust for program evaluation and quality purposes. The Children’s Trust provides funding for the program to operate and follows strict data privacy protections for the information collected (for example, following the Family Educational Rights and Privacy Act/FERPA guidelines).

PARENT/GUARDIAN SIGNATURE *

clear

Date * +

FOR STAFF USE ONLY (MUST BE COMPLETED)

ORGANIZATION: Victory For Youth, Inc.

SITE: SLAM! Miami

Referred From: _______________________________________

Behavioral therapy or services	Counseling for emotional concerns
Daily medication (not including vitamins)	Occupational therapy (OT)
Physical therapy (PT)	Special education services in school
Speech/language therapy	None of the above

Autism spectrum disorder	Developmental delay (only if under age 5)
Intellectual/developmental disability (over age 5)	Hearing impairment or deaf
Learning disability (school age)	Medical condition or illness
Physical disability or impairment	Problems with aggression or temper
Problems with attention and hyperactivity (ADHD)	Problems with depression or anxiety
Speech or language condition	Visual impairment or blind
No condition lasting one year or more	Other condition lasting one year or more (please specify): Other condition lasting one year or more (please specify):