Parent/Guardian Information

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* 1. Youth Name

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* 2. Name of person filling out this form

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* 3. What is your Date of Birth?

Date

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* 4. Your Age

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* 5. Your Relationship to the Youth

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* 6. What is your Marital Status?

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* 7. Your cell number? If you don't have one, type N/A

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* 8. What is your email address? If Unknown Type N/A

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* 9. If you currently work, please list your employer/occupation.

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* 10. Alternate Parent/Guardian Name (spouse, etc)

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* 11. Alternate Date of Birth

Date

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* 12. Alternate Contact Age

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* 13. Alternate Relationship to the Youth

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* 14. Alternate cellphone Number? If unknown, type N/A

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* 15. Select all that apply. I/We have:

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* 16. Does either parent/guardian in the household use tobacco products?

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* 17. If you answered yes, would you, or others in your family, be interested in quitting?

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* 18. If known, Biological Mother Highest Level of Education Completed

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* 19. If known, Biological Father's Highest Level of Education Completed

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* 20. What is your street address?

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* 21. What city do you live in?

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* 22. What is your zip code?

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* 23. Do you own or rent this property?

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* 24. Excluding your child and yourself, is there anyone else living in your home?

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* 25. Do you have any other children NOT living in your home?

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