Youth Club Night Roster

Name:_____________________________________________________________ Male________ Female________

Address:___________________________________________________________ City:________________________
Phone #:(_____)________________________________ E-mail:___________________________________________
Facebook:___________________________ Twitter:___________________________ Birthday:__________________
School:________________________________________ Grade:___________________________________________
Group Home:________________________________________ Phone #:(_____)______________________________
Parent/Caregiver:____________________________________ Phone #:(_____)______________________________

What are some of your interests/hobbies?:____________________________________________________________

What are some of your career interests?:______________________________________________________________
What are your dreams to do or become?:______________________________________________________________
If you could do ANYTHING in the world for a job, what would you do?:_______________________________________
On a scale of 1-10 (10 being the highest), how interested are you in going to college?:______________
On a scale of 1-10 (10 being the highest), how possible do you think it is for you to go to college?:_______________
Are you interested in having a mentor? Yes_____ No_____
If so, what are some activities you would like to do with a mentor?:________________________________________
What would be some important issues with which you would like a mentor to help you? Check all that apply.
Finish High School

Get Into College

Find a Career

Family Issues

Relationship Issues

Others ______________________________________________________________________________________
What are some activities you would like to have at Youth Club Night?:_______________________________________
________________________________________________________________________________________________
If you have been attending Youth Club Night, what do you enjoy the most?:___________________________________
________________________________________________________________________________________________
Where are some of the places you would like to go for fun outings?:_________________________________________
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