APEXTeen Application

Please fill out the form below.

Teen Applicant Information

Applicant's Name: *

First

Middle

Last

Prefered Nickname (if any):

Age: *

Date of Birth: *

Street Address:

Address Line 1

Address Line 2

City

State

Zip Code

Phone: *

Email: *

Does the teen applicant qualify or receive free lunch at school? *

How many times has the applicant moved in the last year? *

Has the teen applicant ever been involved with the juvenile justice system? *

Did the teen applicant ever participate in the youth Camp Mariposa program? *

Teen Activities

Is the teen applicant currently in counseling? *

Teen Family Information

Please indicate the type of substance(s) the teen applicant’s family member(s) has struggled with (check all that apply): *

Other: *

please describe

Does the teen applicant have a family member/guardian in the military (past or present): *

Teen Applicant History

Overdose Lifeline has been providing services for youth and families experiencing issues such as addiction, poverty, abuse and mental health for over a decade. We recognize the following questions may be sensitive information to share, but this will help us plan and prepare a program that will benefit all youth. In the event of current abuse of any type, Overdose Lifeline staff are mandated reporters.

Mental Health

Has teen applicant or anyone in his/her family experienced mental health issues? *

Abuse/Neglect

Has teen applicant experienced abuse? *

Foster Care/Kinship Care

Has the teen applicant had experience in the foster care system (foster parents, group homes, kinship care, adoption)? *

Grief/Loss

Has the teen applicant experienced grief or loss due to death? *

Has the teen applicant experienced separation from family? *

Has the teen applicant experienced incarceration of a family member? *

Program Interest

Teen Applicant T‐shirt style: *

Youth Size
Adult Size

Do you have any concerns about barriers to program participation for your teen? *

Parent/Guardian Contact Information

Name: *

First

Middle

Last

Prefered Nickname (if any):

Age: *

Date of Birth: *

Address: *

Address Line 1

Address Line 2

City

State

Zip Code

Phone: *

Email: *

Relationship to teen applicant: *

Emergency Contacts

Please list two people other than you to contact in case of an emergency at the program.

Emergency Contact #1: *

Relationship to teen applicant: *

Day Phone: *

Evening Phone:

Cell Phone:

Emergency Contact #2 *

Relationship to teen applicant: *

Day Phone: *

Evening Phone:

Cell Phone:

Additional Teen Information

Please list any special needs or physical challenges the teen applicant has: *

Please tell us what it would mean for the teen applicant to participate in the Teen Program: *

Please list any hobbies/interests the teen applicant has: *

Acknowledgment

Teen:

I understand that the Teen Program is yearlong. I will make every effort to attend all activities during the coming year.

Parent/Guardian Signature: *

Date:

Teen Applicant Signature: *

Date:

Want to Get Involved?

Aaron’s Place needs people like you to help as mentors, camp facilitators, and volunteers.

APEXTeen Application

Teen Applicant Information

Teen Activities

Teen Family Information

Teen Applicant History

Mental Health

Abuse/Neglect

Foster Care/Kinship Care

Grief/Loss

Program Interest

Parent/Guardian Contact Information

Emergency Contacts

Additional Teen Information

Acknowledgment

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