Thank you for your interest in A Different Outcome!
Your name (person completing this form)
Your E-mail address
Your Phone Number
Date of Birth
Name of School
Date of Birth
Relationship to youth
Alternate Phone Number
Education/Highest Level Achieved
Number of Children
Emergency Contact Info
Emergency Contact name
Emergency Phone Number
Emergency Contact Relationship to Youth
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?
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.
Some required Fields are empty Please check the highlighted fields.
Providing inner-city youth the opportunity to alter the trajectory of their lives. We believe that early intervention and mentoring will unlock the unlimited potential inherent in our young men.