Bay Area Youth Connections (BAYC) Intake Form

Bay Area Youth Connections (BAYC) Intake Form

Participant Contact Information

First Name

Last Name

Address Line 1

Address Line 2

City

State

Postal Code

Phone

Email

Interested in the following Allied Health Occupations:

Check all that apply

Medical AssistantNurse AssistantPharmacy TechnicianHealth CoachEMT (Emergency Medical Technician)Dental AssistantPhlebotomyOther

You selected 'Other' - please describe what Allied Health Occupations you're interested in that were not listed above:

Tell us more about yourself

Age:

Highest Grade Completed:

I Have a California ID card

YesNo

I Have a Driver's License

YesNo

Justice-Involved Youth?

YesNo

Need Supportive Services in the following areas:

Check all that apply

CounselingCareer CoachingJob PlacementRecord ExpungementSubstance Use CounselingGeneral HealthFoodNutritionHousingAcademic SupportGED CompletionHigh School Diploma CompletionTransportationOther

You selected 'Other' - please describe what supportive services you need that were not listed above:

Referral

How were you referred?

Social MediaWebsiteFlyerFamily/FriendOther

You selected 'Other'- please provide how you were referred