Please provide the following information:

First Name
Middle Name
Last Name
Nickname
Address
City
State
Zip
Date of Birth - Mo/Day/Year
Age
Current Grade
Name of School
Cell Phone
Home Phone
E-mail
Do you have reliable transportation?	Yes     No

How did you hear about Teen Health Connection Girls Group?

Please rate each of the following by checking the appropriate number.
1= Have experience/ like a lot        3= Neutral/middle of the road       5= No experience/ do not like 

I have experience with/ like to do:

Writing  Please choose 1 2 3 4 5	Arts/Crafts Please choose 1 2 3 4 5
Reading   Please choose 1 2 3 4 5	Camping  Please choose 1 2 3 4 5
Computers  Please choose 1 2 3 4 5	Dancing  Please choose 1 2 3 4 5
Singing Please choose 1 2 3 4 5	Leading others  Please choose 1 2 3 4 5
Cooking  Please choose 1 2 3 4 5	Helping others  Please choose 1 2 3 4 5
Music  Please choose 1 2 3 4 5	Fashion/designing Please choose 1 2 3 4 5

Please respond to the following:

1. Explain why you’d like to be a part of this program. What do you hope to contribute? What do you hope to gain?
    
2. Describe your greatest strengths and weaknesses.
    
3. What is your definition of success?
    
4. Please tell us more about yourself.
    
5. Is your health important to you? Yes     No (Explain)

Please respond to the following:

The hardest part about being in High/Middle school is:

I get angry when somebody:

I respond to my anger by: