Member Intake Assessment Form Fill out the Form Demographic Information Name Grade Age School Parent/Guardian Name(s) Emergency Contact Personal Interests and Goals What are your favorite hobbies or activities? What do you want to be when you grow up? What are you most proud of? Self-Assessment Rate yourself from 1 (needs improvement) to 5 (excellent): Emotional Control: 1 2 3 4 5 Working in Groups: 1 2 3 4 5 Solving Problems: 1 2 3 4 5 Communicating Ideas: 1 2 3 4 5 Respecting Others: 1 2 3 4 5 Do you have regular access to a computer or phone with internet? Yes No Technology Use What do you usually do online? Who do you turn to when you’re struggling? Program Goals Do you feel supported at home? What would you like to learn or improve during your time in the program? What do you need help with right now? Message Submitt
