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HOME
ABOUT US
AFTER-SCHOOL PROGRAM
PARTICIPATING SCHOOLS
CAREERS
CONTACT
PRIVACY POLICY
Student Enrollment Form
Child
First Name
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Last Name
(*)
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DOB
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Age
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Grade
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Parent or Guardian
First Name
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Last Name
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Household Status
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Single
Married
Divorced/Separated
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Relationship
(*)
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What does your child identify as?
(*)
Male
Female
Other
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Other
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Primary Language
(*)
English
Spanish
Other
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Other
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Phone
(*)
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E-mail
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Zip Code
(*)
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School
(*)
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County
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Insurance
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Medicaid
Aetna
Cigna
United Health
Blue Cross Blue Shield
None
Other
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Other
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Is your child currently receiving treatment?
(*)
Yes
No
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If yes, what are they being treated for?
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How did you hear about us?
(*)
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I approve the release of this information to School Administrators and Confident Young Minds for the purpose of qualifying my child for this program.
(*)
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I also agree to be contacted by Confident Young Minds and School Administrative staff to address follow up questions regarding this application.
(*)
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If my child is determined eligible, I agree to complete the intake process and assessments within five (5) business days of notification.
(*)
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