Submitting your application…

T.A.R.G.E.T.S Workshop - Application

Participant Information

Full Name *

Date of Birth *

Age *

Grade in School *

School Name *

Student Email *

Student Phone *

Current Courses & Grades

(Please list all classes you are currently taking and your most recent grades.)

Course Name	Current Grade

Parent/Guardian Information

Parent/Guardian #1 Name *

Relationship to Participant *

Phone Number *

Email Address *

Home Address *

Additional Parent/Guardian (Optional)

Parent/Guardian #2 Name

Relationship

Phone Number

Email Address

Medical Information

(This information is confidential and used only for emergency preparedness.)

Primary Physician Name

Physician Phone

Medical Conditions / Allergies

Medications

Emergency Contacts (If different from parent/guardian)

Name

Relationship

Phone

Name

Relationship

Phone

Short Answer Questions

Why are you interested in joining this program? *

What personal goals would you like to work on over the next 10 weeks? *

Describe a challenge you’ve faced and how you handled it. *

How did you hear about this program?

School counselor or teacher Friend Parent/Guardian Social media Community center Flyer or poster Online search Other

If Other, please specify

Do you currently have a mentor?

Yes No

If yes, who is your mentor?

What role do they play in your life?

Permission & Consent

I agree to the Permission & Consent statement above. *

Parent/Guardian Signature (Typed Name)

Date