Strengthening Families Program Application Home / Community Support / Strengthening Families Program / Strengthening Families Program Application Step 1 of 2 50% Referred by* Name* First Name Last Name Address* 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 FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial 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Gender* Race* Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Signature*Date* MM slash DD slash YYYY Spouse/Significant OtherPlease name your spouse or significant other who will be attending.Name First Name Last Name Gender Race Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Phone ChildrenPlease list the names and ages of all your adolescents that are between the ages of 12 and 17 years old (18 if still in high school) who will be attending.1.Name* First Name Last Name Date of Birth* MM slash DD slash YYYY Age* Gender* Race* Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Name of School Your Adolescent Is Attending* Grade* 2.Name First Name Last Name Date of Birth MM slash DD slash YYYY Age Gender Race Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Name of School Your Adolescent Is Attending Grade 3.Name First Name Last Name Date of Birth MM slash DD slash YYYY Age Gender Race Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Name of School Your Adolescent Is Attending Grade 4.Name First Name Last Name Date of Birth MM slash DD slash YYYY Age Gender Race Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Name of School Your Adolescent Is Attending Grade 5.Name First Name Last Name Date of Birth MM slash DD slash YYYY Age Gender Race Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Name of School Your Adolescent Is Attending Grade 6.Date of Birth MM slash DD slash YYYY Name First Name Last Name Age Gender Race Black/African American White Asian or Pacific Islander Hispanic/Latino Multiracial Other** **If you selected "Other," please specify here: Name of School Your Adolescent Is Attending Grade Contact The Clubhouse via email at TheClubhouse@ashleytreatment.org Once we can resume in-person services, all Clubhouse services, including the meals, will be available at our physical space – location to be announced. 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