Teen Parent Intake Form
First Name
Last Name
Birth Date
Address
City
State
Zip
Home Phone #
Email Address
Other Phone
Cell
Work
Other
Sex:
Male
Female
Are you a U. S. Citizen?
Yes
No
Is English your native language?
Yes
No
Disability (optional)
Check all that apply to you:
Unemployed
Single Parent
Teen Parent
Under-employed
Other (specify )
Employed
Name of employer
Position title
Income $
per hour
per year
Dates of employment
To
Other income sources (child support, etc.)
Source
$
Source
$
Unemployed
Previous employer
Position title
Income $
per hour
per year
Dates of employment
To
Other income sources (child support, etc.)
Source
$
Source
$
Education (check all that apply):
High School Diploma (or last
grade completed
)
GED/EDP
(date obtained)
College
(# of years)
Have you attended HCC before?
Yes
No
Have you applied for financial aid (FAFSAA)?
Date applied
Yes
No
Funding Source (if any)
Who referred you to The Teen Parent Program.?
Program of Study at HCC
Future Goals
How old were you when you had your first child?
Number of dependents under your custody
Child 1:
Male
Female Birth Date
Name
Child 2:
Male
Female Birth Date
Name
Child 3:
Male
Female Birth Date
Name
Child 4:
Male
Female Birth Date
Name
Release of Information:
By submitting this form it is my understanding that the Teen Parent Program staff may seek information from HCC personnel, employers and community agencies that may be used to insure my academic success.
Todays Date:
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