San Bernardino Student Sign Up

Are you completing this form for yourself, or someone else?

If completing this form for someone else, enter your name and phone number:

Client Information Enter the information of the person interested in the San Bernardino Life Skills Program

First Name

Last Name

Birth Date

Phone

Email

School

Student ID

Services Needed Check all needs that apply

Life Skills/Independence

Job Skills/Training

Job Placement/Employment

Help Reaching Life Goals

Help With Legal Issues

Other

If other, describe:

What specific help do you need?

Demographics

Ethnicity

Gender

Sexual Orientation

Primary Language Spoken at Home

Education Information

Education Status

Are You Currently Attending School

Grade/Year

Current GPA

Highest Level of Education Completed

Are you struggling in school?

Have you been suspended or expelled?

If yes, how many times?

Do you have any Community/Volunteer Hours to complete?

If yes, how many and by when?

Optional Questions

Do you have extensive history within the criminal justice system? More than one negative interaction with law enforcement

Have you previously been incarcerated?

Are you currently on probation or parole?

Are you currently affiliated with any gangs or live in a gang affiliated neighborhood?

Are you or have you ever been a victim of violence, including gang violence? Free services offered

Have you been a victim of a shooting or been shot at?

Do you have a close relative that is an active gang member or has gang associations?

Do you have a relative that has been shot within the last 12 months?

Goals Please select all that apply

Short Term Goals

Use Ctrl to select all that apply

Long Term Goals

Use Ctrl to select all that apply