Profile Form

Fill in your answers and click on the SUBMIT button.

*This form will be kept strictly confidential

CONTACT INFORMATION

Name:


Birthday:


Home Address:


Home Phone:


Personal Email (Please do not use school email):


Date of the program you're attending:

Are you attending with a family member or friend: Yes No

If yes, what is their name:


Their relationship to you:

Would you like to sit together: Yes No

Will you need any physical assistance while attending Y&M?:


Do you have any dietary restrictions or food allergies that we should know about?:



EDUCATION

High School Student
High School Graduate
College Student
College Graduate - Degree(s) Earned:



ABOUT YOU

How do you see yourself? Check all that apply:

creative life of the party easygoing outspoken optimistic impulsive determined leader

funny confident risk taker flexible smart happy adventurous

shy responsible generous quiet independent compassionate spiritual

Any we've left out:


What activities do you enjoy? Check all that apply:

Playing Sports Computers Reading Traveling Working Out

Shopping Art/Photography Time with Friends/Family Playing Music Church Activities

Dance Computer/Video Games Outdoor Activites TV/Movies Writing

Other:


Clubs/groups you're a member of:



MORE ABOUT YOU

What accomplishment are you most proud of?


What have you done that you were least proud of?



TIME

When I had a assignment that I really don't want to do, I usually:
A: Put it off until the last possible moment
B: Complete it as soon as possible so that I have more time for the things I enjoy
C: Do it in time, but I don't like the end result


If I have an exam coming up, I usually:
A: Study some every day
B: Study for long stretches of time, two or three days before the exam
C: Cram the night before
D: Wing it

Do you use a calendaring tool? Yes No

If so, which type of calendar do you use? (ie. Outlook, smart phone, paper calendar, planner)



MONEY

I live:
alone
with a roommate
with my spouse/family
with my parents


Do you rent or own? Rent Own

Do you have a car? Yes No

About how much money do you spend in a month? $

How much do you owe for school loans, credit card? $

Do you find it easy to save money? Yes No

Are you comfortable with the amount of money you have? Yes No

If not, how much more per month would make you comfortable? $

Do you feel you need to change the way you manage money? Yes No
If yes, please explain:



RELATIONSHIPS

Do you have a mentor? If so, who? Why is this person your mentor?


Do you often find it difficult to socialize with new people? Why or why not?



VISION

Without considering pay or school, which three careers do you think would make you happiest?


Now considering pay and education, which three careers do you think would make you happiest?


What three things are most important to you in a job?


Briefly describe what you'd like your life to be like in 5 years. Where would you live? What job would you have?



What 5 things do you hope to learn from Young&Motivated



Thanks! Your answers will be kept confidential and will be used to customize the program to your needs.