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info@inheritanceacademy.org
Baltimore, MD
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443-840-9077
info@inheritanceacademy.org
Baltimore, MD
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Programs
Infants
Preschool
Before & After Care
Summer, Winter, & Spring Breaks
Inheritance at BMPCS
Active Achievers Youth H.E.L.P
About
About Us
Why Choose Us
Health & Safety
Careers
Tuition Support
Careers
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Programs
Infants
Preschool
Before & After Care
Summer, Winter, & Spring Breaks
Inheritance at BMPCS
Active Achievers Youth H.E.L.P
About
About Us
Why Choose Us
Health & Safety
Careers
Tuition Support
Careers
Location
Enroll Today
Contact Us
Active Achievers Youth H.E.L.P
Step
1
of
5
20%
First Name:
(Required)
Last Name:
(Required)
Gender:
(Required)
Male
Female
Date of Birth:
(Required)
Month
Day
Year
Age:
(Required)
Address:
(Required)
City:
(Required)
Postal Code:
(Required)
Cell Phone Number:
(Required)
Home Phone Number:
(Required)
Email Address:
(Required)
Is The Youth Currently Attending School?
(Required)
Yes
No
Current School:
Grade:
Languages Spoken:
Families Cultural Background:
Do You Need An Interpreter?
(Required)
Yes
No
Which Best Applies To The Youth?
(Required)
Citizen
Permanent Resident
Refugee
Other
Specify If Other:
Does The Youth Identify As A Newcomer?
(Required)
Yes
No
Is The Youth On Any Medication That We Need To Be Aware Of?
(Required)
Yes
No
If Yes, Describe:
Any Allergies?
(Required)
Yes
No
If Yes, Describe:
Does The Youth Have Any Emotional, Mental, Physical, Or Specific Medical Health Conditions That We Should Know About?
(Required)
Yes
No
If Yes, Describe:
Is The Youth In Counseling Or Receiving Services From Child Protective Services?
(Required)
Yes
No
If Yes, Describe:
Is The Youth Or Family Currently Involved With Child Protective Services?
(Required)
Yes
No
What Is The Level Of Involvement?
Family Enhancement
Protection
Office Location:
Phone Number:
Social Worker’s Name:
Emergency Contact Information
Contact Name:
Relationship:
Phone No.1:
Phone No.2:
Parent/Guardian Information Where Applicable And Youth Ages 12 - 17 Years Old
Parent/Guardian's First And Last Name:
Relationship:
Phone Number:
Email Address:
Languages Spoken:
Do You Need An Interpreter?
Yes
No
Other Parent/Guardian(S) Name(S) If Any:
(Enter N/A if not applicable)
Relationship:
Phone Number:
Getting To Know The Youth This Will Help Us With Matching The Youth With A Compatible Mentor
Why Does The Youth Need/Want A Mentor?
(Required)
Tell Us About The Youth’s Personality And Strengths
(Required)
What Would You Say Are Some Of The Youth's Challenges?
(Required)
Is There Anything You Would Like Us To Be Aware Of That Would Assist Us In Finding The Right Mentor For The Youth?
(Required)
Yes
No
If Yes, Please Describe:
List Some Of The Goals/Changes The Youth Would Like To Achieve While In The Program. This Could Either Be Academic, Social, And Personal Skills, Cultural Connection, Professional Development, Networking, Communication Skills, Leadership Skills, Or Other Skills:
(Required)
How Did You Hear About This Program? Select All That Applies:
(Required)
The Academy Builders
Social Media
The Academy Builders Email Newsletter
Word Of Mouth
Other
Specify If Other:
By Ticking On The Checkbox Bellow, You Consent To Receive Services From The Academy Builders
I Agree To The Terms Mentioned Above
Complete Name:
Referral To Be Completed By The Referring Agency Only
Referring Agency:
Referred By:
(Name of Referrer)
Phone Number:
Email Address: