Route 21 Youth & Parent/Guardian Application

To guardians/parents... Thank you for taking the time to fill out this questionnaire. The questionnaire is vital in helping Route 21 serve your youth well. All information is kept confidential.

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Guardians Name(Required)
Address(Required)
Student's Name(Required)
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Please check the boxes that you are concerned about for your youth.
Do you plan on moving in the next four years?
Route 21 mentors and staff have video cameras in their car to record all activities in the car while they are with youth. The footage will never be used for promotion or advertising. The footage is just used to keep Route 21 youth and staff safe. Are you okay with your youth being recorded while in the car with Route 21 staff?

Thank you for taking the time to fill out this application. The many questions help us serve your youth better. Route 21 will get back to you shortly.