Embrace Application Step 1 of 7 14% Student InformationName* First Last Legal name (if different) First Last Date of birth* Date Format: MM slash DD slash YYYY Gender*MaleFemaleTransgender MaleTransgender FemalePreferred pronounsHeight*Weight*Religious preferenceCurrently enrolled in school*YesNoCurrently employed*YesNoAddressAddress* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary parent / sponsor informationName* First Last Relationship*Sponsor*YesNoPreferred pronounsEmergency contactDate of birth Date Format: MM slash DD slash YYYY Contact InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home phoneMobile phoneEmail Employment InformationEmployerJob TitleWork PhoneWork Email Secondary Parent/SponsorName First Last RelationshipSponsorYesNoPreferred PronounsEmergency contactDate of birth Date Format: MM slash DD slash YYYY Contact InformationAddress Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzech RepublicCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatini (Swaziland)EthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacauMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaRéunionSaint BarthélemySaint HelenaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth GeorgiaSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan Mayen IslandsSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Home PhoneMobile PhoneEmail Employment InformationEmployerJob TitleWork PhoneWork emailBriefly describe your relationship with second parent/sponsor: Referral InformatonHow did you first hear about Skyterra Embrace?*Please give the name of the referral source:Reason for referral:What specific events precipitated your decision to receive additional support?*What are your specific goals while participating in Skyterra Embrace?*What would you describe as your strengths (intellectually, artistically, socially, physically, etc.)?*What would you describe as your areas of growth (intellectually, artistically, socially, physically, etc.)?*Please describe your experience with the outdoors and other physical activities:*Educational InformationWhat is the highest grade you have completed?*Name of current school, if applicable:Academic strengths/interests:* Psychological HistoryPlease describe any major events you have experienced (divorce, moving, birth of sibling, loss, death, abuse, illness, etc.). Please include the date the event occurred:Have you ever been diagnosed with a mental health disorder by a licensed professional (therapist, counselor, physician, etc)?*YesNoIf yes, please include details:Describe the way(s) in which you express anger:Have you had any physical confrontations or altercations with others?*YesNoIf yes, please describe:Suicidality and Self-Injury: Have you ever had thoughts of suicide, made a plan, or attempted suicide?*YesNoIf yes, please describe (specify date):Have you ever intentionally hurt yourself?*YesNoIf yes, please describe (specify dates):Sexual activity: Please describe any risky, aggressive or inappropriate sexual behaviors (promiscuity, unprotected sex, perpetrating, deviance, etc.):Mood: Do you experience symptoms of anxiety, depression, mood swings, etc.?*YesNoIf yes, please describe:Obsessions/Compulsions: Do you experience recurrent thoughts or repeated behaviors that you have difficulty controlling?*YesNoIf yes, please describe in detail including dates:Lying, stealing, vandalism, dealing drugs, criminal activity:*YesNoIf yes, please describe in detail including dates:Unusual Behaviors (current or past):*YesNoPlease describe in detail including dates:Eating Issues (current or past):*YesNoIf yes, please describe in detail including dates:Isolation: Do you struggle with isolation?*YesNoIf yes, please describe in detail:Motivation: Do you struggle to get out of bed in the morning and engage in the day?*YesNoIf yes, please describe in detail:Substance-Related Issues: Do you experience any alcohol, substance and/or dependency related issues?*YesNoIf yes, describe when you first engaged in substance use and the choice of substance, usage patterns/frequency and how administered; please include cigarette use:Other addictive patterns (eg: computer games, T.V., phone, internet, sex, gambling):*YesNoIf yes, please describe:Legal Problems:*YesNoIf yes, please list any charges, convictions, misdemeanors, felonies, probation and current legal status: Nutrition InformationDo you have any food allergies/intolerances?Do you have any specific food dislikes?How many meals per day do you typically eat?*What does your typical breakfast consist of?*What does your typical lunch consist of?*What does your typical dinner consist of?*Do you eat snacks throughout the day? If so, how frequently and what do they consist of?*Do you have any unusual eating patterns/behaviors?*How would you describe your current relationship with food?*How would you describe your current relationship with exercise?*How would you describe your current relationship with your body?* Medical informationDate of last physical: Date Format: MM slash DD slash YYYY Please list any surgeries, serious illness and/or hospitalizations. Please include date/event:Please list any prescription and/or over-the-counter medications you are currently taking and the reasons for each (include dosage, prescribing physician/phone number):Are there any known side effects of the medication?*YesNoIf yes, please describe:Do you manage medications appropriately and follow prescribed medication regimen without support from others?*YesNoDescribe any pertinent medical/physical information that might inhibit physical activity:Do you have any dietary restrictions?*YesNoIf yes, please describe:ImmunizationsAre you up-to-date on immunizations?*YesNoDate of last immunization:Flu: Date Format: MM slash DD slash YYYY Covid-19: Date Format: MM slash DD slash YYYY Tetanus/Diphtheria: Date Format: MM slash DD slash YYYY Measles, Mumps, Rubella: Date Format: MM slash DD slash YYYY Hepatitis B: Date Format: MM slash DD slash YYYY Polio: Date Format: MM slash DD slash YYYY Allergies/asthma:List all allergies (food, medication, grasses, etc.), how activated and what happens:Do you carry an inhaler or epinephrine pen?*YesNoHave you ever been hospitalized for allergies/asthma?*YesNoIf yes, please describe (include date/reason):I agree* By checking this box, you agree that all information you have provided in this application is accurate and the most current information, and there has been no false information included
