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Online Application

Home › Online Application

Please complete this application as a first step toward enrolling your teen in AHA!.
Once you hit “submit,” you will receive communications from us about next steps.

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STUDENT INFORMATION:

Name:

Date of Birth:

Day:

Month:

Year:

Address:

City:

State:

Zip Code:

Student's Home Phone:

Student's Cell:

Student's email address:

PARENT/GUARDIAN(S) INFORMATION:

Name:

Relationship:

Address (if different from above):

Email: (This email will receive confirmation email)

Parent's Home #:

Parent's Work #:

Parent's Cell #:

Do you speak:

EnglishSpanishBilingual

What's your combined monthly household income?

How many family members live in your household?

What was the highest level of education you completed?

What's your ethnic background? (not required but helpful to AHA!)

PARENT SURVEY

What are your child’s strengths?

What concerns do you have regarding your child?

What changes are you hoping to see through your child’s participation in AHA!

What medical or emotional issues would you like to share about your teen?

REFERRED BY:

N/AFriendSchoolProfessional

Name:

Phone:

Position/Title:

Email:

SCHOOL INFORMATION:

School:

Grade:

School Year:

EMERGENCY CONTACT INFORMATION:

Name:

Relationship:

Home Phone:

Work Phone:

Cell Phone:

Email:

WHAT PROGRAMS ARE YOU INTERESTED IN PARTICIPATING IN?:

AHA! ConnectPeace Builders 2.0Girls Relationship Wisdom GroupAHA! Guys’ GroupTuesday Ally GroupCreative Group#TBH (#To Be Honest)Music Group SummaryOutdoor GroupCarpinteria GroupSummer Intensive ProgramSing It OutLittlest Little Farm

SELECT YOUR SCHOOL (If applicable):

Santa Barbara JHLa Colina JHLa Cumbre JHGoleta Valley JHCarpinteria HSSanta Barbara HSSan Marcos HSDos Pueblos HS

We offer our out-of-school programs by donation. Please donate what you can; any amount is accepted. Thank you for supporting AHA! Click here to donate.

If your family is unable to donate, please contact Interim Executive Director Roxana Petty at roxana@ahasb.org

We are a 501(c)(3) organization.