MATCH Program Application
Today's Date (MM/DD/YYYY)
PARTICIPANT INFORMATION
First Name
MI
Last Name
Address Line 1
Address Line 2
City
Country
Please select...
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos ( Keeling ) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
State
Please select...
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Postal Code
Phone
Date of Birth (MM/DD/YYYY)
Are You/Your Child enrolled in Medi-Cal?
Please select...
Yes
No
Not Sure
Gender
Please select...
Male
Genderqueer/Non-Binary
Female
Decline to State
Ethnicity: Hispanic/Latino/a?
Yes
No
Race: (Check all that apply)
Black/African American
Asian
American Indian/Alaskan Native
White
Native Hawaiian/Other Pacific Islander
Other or Multiracial
School
Please select...
1-Other
ACORN WOODLAND ELEMENTARY SCHOOL
ALLENDALE ELEMENTARY SCHOOL
ALLIANCE ACADEMY
BELLA VISTA ELEMENTARY SCHOOL
BERKELEY ARTS MAGNET AT WHITTIER (BAM)
BERKELEY HIGH SCHOOL
BERKELEY TECHNOLOGY ACADEMY
BRET HARTE MIDDLE SCHOOL
BRIDGES ACADEMY
BROOKFIELD ELEMENTARY SCHOOL
BURCKHALTER ELEMENTARY SCHOOL
CARL B. MUNCK ELEMENTARY SCHOOL
CASTLEMONT HIGH SCHOOL
CHABOT ELEMENTARY SCHOOL
CLAREMONT MIDDLE SCHOOL
CLEVELAND ELEMENTARY SCHOOL
COLISEUM COLLEGE PREP ACADEMY
COMMUNITY DAY SCHOOL
COMMUNITY UNITED ELEMENTARY SCHOOL
CRAGMONT ELEMENTARY
CROCKER HIGHLANDS ELEMENTARY SCHOOL
DEWEY ACADEMY
EAST OAKLAND PRIDE ELEMENTARY SCHOOL
EDNA BREWER MIDDLE SCHOOL
ELMHURST COMMUNITY PREP SCHOOL
EMERSON ELEMENTARY
EMERSON ELEMENTARY SCHOOL
ENCOMPASS ACADEMY
ESPERANZA ELEMENTARY SCHOOL
FRANKLIN ELEMENTARY SCHOOL
FRED T. KOREMATSU DISCOVERY ACADEMY
FREMONT HIGH SCHOOL
FRICK IMPACT ACADEMY
FRUITVALE ELEMENTARY SCHOOL
FUTURES ELEMENTARY SCHOOL
GARFIELD ELEMENTARY SCHOOL
GATEWAY TO COLLEGE AT LANEY COLLEGE
GLENVIEW ELEMENTARY SCHOOL
GLOBAL FAMILY SCHOOL
GRASS VALLEY ELEMENTARY SCHOOL
GREENLEAF ELEMENTARY SCHOOL
HILLCREST ELEMENTARY SCHOOL
HOOVER ELEMENTARY SCHOOL
HORACE MANN ELEMENTARY SCHOOL
HOWARD ELEMENTARY SCHOOL
INTERNATIONAL COMMUNITY ELEMENTARY SCHOOL
JEFFERSON ELEMENTARY
JOAQUIN MILLER ELEMENTARY SCHOOL
JOHN MUIR ELEMENTARY
KAISER ELEMENTARY SCHOOL
LA ESCUELITA ELEMENTARY SCHOOL
LAUREL ELEMENTARY SCHOOL
LECONTE ELEMENTARY
LIFE ACADEMY
LINCOLN ELEMENTARY SCHOOL
LONGFELLOW MIDDLE SCHOOL
MADISON PARK ACADEMY PRIMARY
MADISON PARK ACADEMY SECONDARY
MALCOLM X ELEMENTARY
MANZANITA COMMUNITY SCHOOL
MANZANITA SEED
MARKHAM ELEMENTARY SCHOOL
MARTIN LUTHER KING JR. MIDDLE SCHOOL
MARTIN LUTHER KING, JR. ELEMENTARY SCHOOL (PK-3)
MCCLYMONDS HIGH SCHOOL
MELROSE LEADERSHIP ACADEMY
METWEST
MLK / LAFAYETTE ELEMENTARY SCHOOL (4-5)
MONTCLAIR ELEMENTARY
MONTERA MIDDLE SCHOOL
NEW HIGHLAND ACADEMY
OAKLAND HIGH SCHOOL
OAKLAND INTERNATIONAL HIGH
OAKLAND SOL
OAKLAND TECHNICAL HIGH SCHOOL
OXFORD ELEMENTARY
PARKER ELEMENTARY SCHOOL
PERALTA ELEMENTARY SCHOOL
PIEDMONT AVENUE ELEMENTARY SCHOOL
PLACE @ PRESCOTT
RALPH J. BUNCHE HIGH SCHOOL
REACH ACADEMY
REDWOOD HEIGHTS ELEMENTARY SCHOOL
RISE COMMUNITY SCHOOL
ROOSEVELT MIDDLE SCHOOL
ROOTS INTERNATIONAL ACADEMY
ROSA PARKS ELEMENTARY
RUDSDALE CONTINUATION
SANKOFA ACADEMY
SEQUOIA ELEMENTARY SCHOOL
SKYLINE HIGH SCHOOL
SOJOURNER TRUTH INDEPENDENT STUDY
STREET ACADEMY
THINK COLLEGE NOW ELEMENTARY SCHOOL
THORNHILL ELEMENTARY SCHOOL
THOUSAND OAKS ELEMENTARY
UNITED FOR SUCCESS
URBAN PROMISE ACADEMY
WASHINGTON ELEMENTARY
WEST OAKLAND MIDDLE SCHOOL
WESTLAKE MIDDLE SCHOOL
WILLARD MIDDLE SCHOOL
Grade
Please select...
Pre-Kindergarten
Kindergarten
1st Grade
2nd Grade
3rd Grade
4th Grade
5th Grade
6th Grade
7th Grade
8th Grade
9th Grade
10th Grade
11th Grade
12th Grade
Some Highschool
Highschool Graduate
Some College
College Graduate
Other
MEDICAL HISTORY AND COVERAGE
NAME OF FAMILY DOCTOR
Phone
HEALTH INSURANCE PROVIDER
INSURANCE ID #
HAS THE PARTICIPANT COMPLETED THE FOLLOWING?
Chicken Pox Shots
Please select...
YES
NO
Mumps Shots
Please select...
YES
NO
TB Test Shots
Please select...
YES
NO
Tetanus Booster Shots
Please select...
YES
NO
German Measles Shots
Please select...
YES
NO
DOES THE PARTICIPANT HAVE
Asthma
Please select...
YES
NO
Vision Problems
Please select...
YES
NO
Hearing Problems
Please select...
YES
NO
Speech Problems
Please select...
YES
NO
DOES THE PARTICIPANT HAVE ANY OF THE FOLLOWING ALLERGIES?
Food
Please select...
YES
NO
Insect Bites
Please select...
YES
NO
Medications
Please select...
YES
NO
Plants
Please select...
YES
NO
Other Allergies not listed above, please specify
Special Health Needs
Adult(s) Living with Participant Contact Details
Parent/Guardian (Primary)
First Name
Last Name
Daytime Phone
Cell Phone
Email
Relationship with Participant
Please select...
Mother
Father
Aunt
Uncle
Grandparent
Sibling
Cousin
Other
EMERGENCY CONTACT
First Name
Last Name
Daytime Phone
Cell Phone
Email
Relationship with Participant
Please select...
Mother
Father
Aunt
Uncle
Grandparent
Sibling
Cousin
Other
INCOME ELIGIBILITY
Please attach recent Bank Statement, Payroll Stub, Tax Return or Self-Certify to apply for services under BYA's Discounted Fee Schedule.
Check all that apply
Single Parent Family
Disabled
Chronically Homeless
Homeless/Couch Surfing
Previous or Current Foster Youth
Pregnant or Parenting
Employed or in Job Training?
Family Receives Public Assistance?
Please select...
YES
NO
AFDC/TANF/Cal Works?
Please select...
YES
NO
Cal FRESH (Food Stamps)?
Please select...
YES
NO
Medi-Cal?
Please select...
YES
NO
Social Security Income (SSI)?
Please select...
YES
NO
Disability?
Please select...
YES
NO
Unemployment?
Please select...
YES
NO
Other, Self-Certify
HOUSEHOLD SIZE
Please select...
1
2
3
4
5
6
INCOME LEVEL
Please select...
$11,770
$15,930
$20,090
$20,500
$23,400
$24,250
$26,350
$28,410
$29,250
$31,600
$32,570
$33,950
$34,150
$39,000
$43,900
$48,750
$52,650
$56,550
$60,150
$67,650
$75,150
$81,200
$87,200
How were you referred?
Please select a choice below
Social Media
Flyer
BYA Website
Family/Friend
Other
You selected 'other' please provide how you were referred below
Contact Information