Member Information Member Name Date of Birth Member Phone Gender MaleFemaleOtherPrefer Not to Answer Current Address City State Zip School Attending School City Grade Ethnicity Parent/Guardian Information Parent/Guardian #1 Parent/Guardian Name Relation to Member Phone 1 CellHomeWork Phone 2 CellHomeWork Email Parent/Guardian #2 Parent/Guardian Name Relation to Member Phone 1 CellHomeWork Phone 2 CellHomeWork Email Emergency Contact Contact Name Relation to Member Phone Member Medical Health Information Known Medical Issues Allergies Medications Taken Member Socioemotional Information VSOY STAFF AIMS TO TAILOR PROGRAMMING TO MEET THE NEEDS OF OUR MEMBERS. THIS INFORMATION IS OPTIONAL AND IS COLLECTED TO HELP US MEET YOUR CHILD’S SPECIFIC NEEDS. THIS INFORMATION WILL NOT BE SHARED. VSOY STAFF MEMBERS ARE NOT LICENSED OR TRAINED MENTAL HEALTH PROFESSIONALS. Known Behavioral Concerns Current Interventions Partnering Organizations (DCF, TEAM Inc., BH Care, etc.) Members Interests/Hobbies/Aspirations Household Demographics THIS INFORMATION IS COLLECTED FOR GRANT PURPOSES ONLY. Member Lives With Both ParentsMotherFatherGrandparentDCF/Foster CareOther Single Parent? YesNo Head of Household MaleFemaleOther Annual Household Income $0 - $10,000$10,000 - $30,000$30,000 - $50,000$50,000 - $70,000$70,000 - $90,000$90,000+ Military Household YesNo Branch I have read the Valley Save Our Youth Handbook and Agree to the Policies.