ReRoute Youth Intake & Referral Form Complete this form to begin your journey with the ReRoute program and access supportive services. Youth Information Youth Full Name* First NameLast Name Date of Birth* -Month -DayYearDate Age* Gender* MaleFemaleNon-binaryPrefer not to sayPrefer to self-describe Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Email Address* example@example.com Home Address* Street Address Street Address Line 2CityState / ProvincePostal / Zip Code Please Select Afghanistan Albania Algeria American Samoa Andorra Angola Anguilla Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan The Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bosnia and Herzegovina Botswana Brazil Brunei Bulgaria Burkina Faso Burundi Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Cote d'Ivoire Croatia Cuba Curaçao Cyprus Czech Republic Democratic Republic of the Congo Denmark Djibouti Dominica Dominican Republic Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands Faroe Islands Fiji Finland France French Polynesia Gabon The Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati North Korea South Korea Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macau Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Nagorno-Karabakh Namibia Nauru Nepal Netherlands Netherlands Antilles New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island Turkish Republic of Northern Cyprus Northern Mariana Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Islands Poland Portugal Puerto Rico Qatar Republic of the Congo Romania Russia Rwanda Saint Barthelemy Saint Helena Saint Kitts and Nevis Saint Lucia Saint Martin Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Slovakia Slovenia Solomon Islands Somalia Somaliland South Africa South Ossetia South Sudan Spain Sri Lanka Sudan Suriname Svalbard eSwatini Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Transnistria Pridnestrovie Trinidad and Tobago Tristan da Cunha Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam British Virgin Islands Isle of Man US Virgin Islands Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe Other Country School Currently Attending* Current Grade Level* Please Select 6th 7th 8th Freshman Sophomore Junior Senior GED Program Graduated Not Currently Enrolled Referral Information Who is completing this form?* Parent/GuardianProbation OfficerSchool StaffOutreach WorkerCase ManagerYouth Self-ReferralOther Name of referring adult* Organization or agency* Relationship to youth* Contact phone number* Please enter a valid phone number.Format: (000) 000-0000. Contact email* example@example.com Program Participation Interested in paid participation opportunities?* YesNoUnsure Transportation assistance needed?* YesNoSometimes Barriers preventing participation* If transportation assistance is needed, what is the transportation for?* Emergency Contact Emergency Contact Name* First NameLast Name Emergency Contact Phone Number* Please enter a valid phone number.Format: (000) 000-0000. Relationship to Youth* Communication & Media Communication preferences* Phone callsText message updatesEmail updatesProgram reminders Photo/video release* Yes, I allow photo/video use for program promotionNo, I do not allow photo/video use Text message opt-in* Yes, I agree to receive text updates and reminders Email updates opt-in* Yes, I agree to receive email updates and reminders Thank-you page note Submit Should be Empty:
