If you would like to learn more about the San Diego American Indian Health/Youth Center or would like to schedule
an appointment for an intake, please complete the form below and submit on line.
Thank you very much. We look forward to meeting with you!

Name:

Age: 9 10 11 12 13 14 15 16 17 18 19 20 21 22

Date of Birth: (Month) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec  (Date) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  (Year)

Grade in School:  

Parent/Guardian(s) Name:  

Email:

Contact Phone Number:
(format: xxx-xxx-xxxx)

Contact Phone Number:
(format: xxx-xxx-xxxx)

Comments: