2026-2027 AHA! Santa Barbara Youth Program Application

Please complete this application as a first step toward enrolling your teen in AHA!.

Please only submit one application per teen per term. Once enrolled, if you would like to add additional groups/programs, please contact Director of Enrollment, Paulina Romero, via email at paulina@ahasb.org, or text at (805) 229-1079

New to AHA! or returning

New (has never participated in an AHA! After School Group or is returning after a long break)Returning (has completed an application and participated in AHA! After School Groups within the last year)

New Student Information

Student First Name

Student Last Name

Student Birthdate

Student's Preferred Pronouns

Student Mobile Phone

Student Personal Email

Student Home Phone

Street Address

City

Country

State

Postal Code

What is your student's race?

Is your student Hispanic or Latino?

What is your student's gender?

What is your student's preferred language?

Returning Student Information

Student First Name

Student Last Name

Has any of your contact information changed in the past year. If it has changed, please update it below. If it has not changed, you may skip to the *required sections.

YesNo

Student's Preferred Pronouns

Student Mobile Phone

Student Personal Email

Street Address

City

Country

State

Postal Code

What is your student's race?

Is your student Hispanic or Latino?

What is your student's gender?

What is your student's preferred language?

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Relationship

Parent/Guardian Mobile Phone

Parent/Guardian Preferred Email

Parent/Guardian Home Phone

Parent/Guardian Preferred Phone Type

MobileHomeOther

Parent/Guardian Address Information (if different from student address above)

Street Address

City

Country

State

Postal Code

What was the highest level of education you completed?

Which is the primary language spoken at home?

Other Language Spoken at Home

Would you like to be added to our Newsletter and parent communications?

YesNo

Would you like to add a second guardian/emergency contact to receive AHA! Communications? (if yes, please fill out information below)

Yes No

Rounded Combined Annual Household Income

Second Guardian/Emergency Contact Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Relationship

Parent/Guardian Preferred Phone

Parent/Guardian Preferred Email

Parent/Guardian Address Information (if different from student address above)

Street Address

City

Country

State

Postal Code

What was the highest level of education you completed?

Which is the primary language spoken at home?

Other Language Spoken at Home

Would you like to be added to our Newsletter and parent communications?

YesNo

Updated Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Has any of your contact information changed in the past year. If it has changed, please update it below. If it has not changed, you may skip to the *required sections.

YesNo

Parent/Guardian Relationship

Parent/Guardian Prefered Phone Number

Parent/Guardian Mobile Phone

Parent/Guardian Preferred Email

Parent/Guardian Address Information (if different from student address above)

Street Address

City

Country

State

Postal Code

What was the highest level of education you completed?

Which is the primary language spoken at home?

Other Language Spoken at Home

Would you like to add a second guardian to receive AHA! Communications? (if yes, please fill out information below)

Yes No

Rounded Combined Annual Household Income

I am aware that I will be asked to make a donation upon enrollment

Yes

Second Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Relationship

Parent/Guardian Other Relationship

Parent/Guardian Preferred Phone

Parent/Guardian Preferred Email

Parent/Guardian Address Information (if different from student address above)

Street Address

City

Country

State

Postal Code

What was the highest level of education you completed?

Which is the primary language spoken at home?

Other Language Spoken at Home

Would you like to be added to our Newsletter and parent communications?

YesNo

Parent Survey

What are your student's strengths?

What concerns do you have regarding your student?

What changes are you hoping to see through your student's participation in AHA!

If you would like to share about any medical or psychological issues that affect your student, please do so here:

If you have any concerns about your child’s ability to participate in AHA! group activities, please share them here:

Referral Information

Referral First Name

Referral Last Name

Referral Organization Name (if applicable)

Referral Organization Name (if not listed in dropdown above)

Referral Preferred Phone

Referral Preferred Email

School Information

School Name

Add Full School Name

Grade Level

School Year

High School Graduation Year