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Student Intake Form

Full Name *

Phone

Email *

Grade *

Student Grade

6
7
8
9
10
11
12
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School Name *

City *

State *

Primary Sport *

Select your Sport

Gymnastics
Football
Soccer
Basketball
Track & Field
Baseball
Swimming/Diving
Wrestling
Volleyball
Tennis
Cheer/Dance
Other
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Hours/week in practice or training *

Self-Awareness & Ownership:

What are 2–3 things going well for you academically right now?

What is the hardest part of school for you?

What causes you the most stress or frustration during the week?

When you’re behind on schoolwork, how do you usually respond?

Procrastinate

Try to catch up fast

Ask for help

Avoid it

What are your biggest distractions when trying to study?

Phone

Friends/social media

Noise

Family responsibilities

Self-doubt

I don’t know

Personal Responsibility + Motivation:

What grade are you hoping for this semester in each class?

Are you motivated to improve your grades this semester?

What would make school feel easier or more doable?

Do you take responsibility for your schoolwork, or do others manage it for you?

What are you most proud of about yourself right now?

Anything you wish your parents or teachers understood better about you?

Communication + Goals:

Are you comfortable talking to your coaches about school and goals?

(Yes/No)

Yes
No
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Are you comfortable advocating for yourself with teachers?

(Yes/No)

Yes
No
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What are your college or career goals (if any)?

Do you want to do your sport in college?

(Yes/No/Not Sure)

Yes
No
Not Sure
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What kind of support would feel helpful from your academic coach?

May we share wins or quotes from your student in newsletters/social media? *

(Yes/No)

Yes
No
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