Youth Program Online Application

For more information about programming and enrollment visit our enrollment page, https://ahasb.org/enrollment/

Please complete this application as a first step toward enrolling your teen in AHA!.
Once you hit “submit,” the webpage will be completely blank, and you will receive communication about the next steps. If information remains in the cells after you submit it, please review the form and update any missing or incorrectly entered the information.
Please submit only one application per teen per term. Once enrolled, if you would like to add additional groups/programs, please contact Community Enrollment Coordinator, Paulina Romero, via email at paulina@ahasb.org, or text at (805)229-1079

2024-2025 - AHA! Santa Barbara Youth Program Application

Please complete this application as a first step toward enrolling your teen in AHA!.

Please submit only one application per teen per term. Once enrolled, if you would like to add additional groups/programs, please contact Enrollment Operations Specialist, Paulina Romero, via email at paulina@ahasb.org, or text at (805) 229-1079

Student Information

Student First Name

Student Last Name

Student Birthdate

Student Personal Email

Student Home Phone

Student Mobile Phone

New to AHA! or returning teen

New

Returning

Street Address

City

Country

State

Postal Code

What is your student's race?

Is your student Hispanic or Latino?

What is your student's gender?

What is your student's preferred language?

Parent/Guardian Information

Parent/Guardian First Name

Parent/Guardian Last Name

Parent/Guardian Relationship

Parent/Guardian Other Relationship

Parent/Guardian Home Phone

Parent/Guardian Work Phone

Parent/Guardian Mobile Phone

Parent/Guardian Preferred Email

Parent/Guardian Preferred Phone Type

HomeMobileWorkOther

Parent/Guardian Preferred Email Type

PersonalWorkAlternate

Note: Email Address provided above will receive confirmation email.

Parent/Guardian Address Information (if different from student address above)

Street Address

City

Country

State

Postal Code

What's your combined monthly household income?

How many family members live in your household? (Type a number)

What was the highest level of education you completed?

Which is the primary language spoken at home?

Other Language Spoken at Home

Would you like to be added to our Newsletter and parent communications?

YesNo

Parent Survey

What are your student's strengths?

What concerns do you have regarding your student?

What changes are you hoping to see through your student's participation in AHA!

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

Referral Information

Referred By

N/A

Friend

School

Professional

Clinics

Referral First Name

Referral Last Name

Referral Position/Title

Referral Organization Name (if applicable)

Referral Organization Name (if not listed in dropdown above)

Referral Phone

Phone Type

HomeMobileWorkOther

Referral Email

Email Type

PersonalWorkAlternate

School Information

School Name

Add Full School Name

Grade Level

School Year

Emergency Contact Information

Contact First Name

Contact Last Name

Contact Relationship

Other Contact Relationship

Contact Home Phone

Contact Mobile Phone

Contact Work Phone

Contact Preferred Phone Type

HomeMobileWorkOther

Edit this heading

Contact Preferred Email

Contact Preferred Email Type

PersonalWorkAlternate

What Programs Are You Interested in Participating In?

Group options that appear below are dependent on grade level selected.

Program Interest for Currently Enrolling Programs. (For High School Students)

SB Summer Intensive ProgramCarpinteria Summer ProgramAHA! Digital Cleanse, Summer 2024Littlest Little Farm

Fall Program Interest (For High School Students)

AHA! ALLY Program (Only Available at SBHS and SMHS)Tuesday Creative Group Wednesday Girls' Group Wednesday Guys' Group Friday EQ Vibes Music Group Littlest Little FarmThursday Sing It Out! (Spring)

Program Interest (For Junior High School Students)

SB Summer Intensive ProgramCarpinteria Summer ProgramIn School AHA! Peace Builders (Only Available at CMS and La Cumbre)Fall Wednesday AHA! Juniors

We require that all families enrolling teens in our programs make a donation toward the cost of delivering those programs.

It is vital that we receive a donation from every family enrolling, even if it is a small one!

Donations can be made at the time of application or upon confirmed placement in an AHA! group.

Please donate whatever your finances allow by sending a check (made out to AHA!) to our physical address (1209 De La Vina St. Suite A, Santa Barbara, CA, 93101), by using the “Donate” button at this website or via Venmo @AHA-SB-1.

Donations are not refundable.

Please add a note to any online donation indicating that it is a donation.

If your family is unable to donate, please contact Executive Director, Roxana Petty at roxy.ahasb@gmail.com

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Contact Information