Online Application - AHA! Santa Barbara

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.
Pleas submit only one application per teen per term. Once enrolled, if you would like to add additional groups/programs, please text or call Enrollment Coordinator, Perla Sandoval, at 805-252-0750.

thanks

cancellation

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 (personal, not school):

New to AHA! or returning teen:

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? Do not include commas.

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?:

SELECT YOUR SCHOOL (If applicable):

We offer our out-of-school programs by donation. Please donate what you can; any amount is accepted. We will follow up with you once your enrollment is received. Thank you for supporting AHA!

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