Our Application

Thank you for your interest in A Different Outcome!

  • Getting Started
  • Youth Information
  • Parent/Guardian
  • Assesment
  • Final

Basic Information

Your name (person completing this form)

Your E-mail address

Your Phone Number

Referring Agency

Participant Information

Name

Age

Date of Birth

Gender

Ethnicity

Name of School

Grade

Parent/Guardian

Name

Address

Date of Birth

Relationship to youth

Phone Number

Alternate Phone Number

E-mail address

Occupation

Education/Highest Level Achieved

Number of Children

Emergency Contact Info

Emergency Contact name

Emergency Phone Number

Emergency Contact Relationship to Youth

Assessment

My Child’s Reading Level is

My Child reads at the ____ grade level.

My Child’s Math Scores are

My Child’s overall grade in math from the last report card is ______.

My Child is a

My Child’s overall grade point average is a ____________.

Please Check the Following boxes to indicate any issues that need close attention:

Are you or your child involved in any other supportive programs?

If you answered yes above, which program(s) are you or your child involved with?

Is there any additional information you would like to share with us?

Consent

I affirm and support my child’s involvement in A Different Outcome (ADO). I understand that A Different Outcome Program is designed to motivate and inspire young men by providing mentoring and training in the areas of: Technology training/Career Counseling, Financial Literacy, and Mental Health.

Name