From a distance, it's an average form like a million others. Black and white, photocopied, the type of thing you might fill in if you were renewing your insurance or applying for a rental apartment.
Yet among the everyday information asked of the young people who fill out the form are questions that, in a shockingly matter-of-fact way, reveal the true tragedy of a community ravaged.
One question, on page two, simply asks if the teenage applicant's mother and father are "alive, dead or missing". Another asks the person to state if they have been sexually abused and provide the dates and details.
Every young person who comes to the Whizzkids United health academy in a rundown area outside of Pietermaritzburg - in the heart of South Africa's HIV epidemic - must fill in the sheet.
They ask because it happens.
In this area, 41 per cent of the population have the still incurable virus and rates among young women are the highest in the world. It's all too common for mothers to die from AIDS, sometimes when their kids are still too young to understand what's happening.
"Many of the children are orphans and find out years later the person they are calling ma is actually their mother's sisters because their mother died when they were two," says Nonhlanhla Madlala, a doctor at Whizzkids United.
One man, she says, lost 80 per cent of his family to HIV. "You actually get pleasantly surprised when you find young people with both parents coming here."
The centre is just up the road from Durban where, this week, thousands of scientists, politicians and even the odd celebrity - including Prince Harry and Hollywood star Charlize Theron - have been gathering for the AIDS 2016 conference.
The 18,000 delegates in attendance have heard treatments to suppress HIV, the virus that leads to AIDS, are effective. Of the 37 million people living with the condition only 17 million are on medication. Rich nations, who help pay for treatment and support programs in developing countries, have been criticised for backing, but not fully funding, a plan to end the AIDS epidemic by 2030.
Speaking to news.com.au in Pietermaritzburg, South African born Theron, said the world's response wasn't good enough. "There's a huge part of me that is incredibly angry that after 30 years we're still in the place we are right now.
"AIDS is completely preventable but we are so late to the game and it's frustrating."
The movie's star outreach project helps fund seven programs in South Africa focusing on HIV including Whizzkids United. Founded in 2000 by two British nurses, the service, which also receives funding from the local health department, provides HIV prevention, care, treatment and support programs to young people while using soccer to teach them about life skills.
Twenty-one year old Ntethelelo Neobese is a regular at Whizzkids. He told news.com.au that many teenagers in the area, wracked with poverty, learn the wrong kind of life skills.
"A young girl, who is 15, her mother passed away with AIDS and she never knew her father," he says.
"She had to drop out at school because she needed to find a way to support her family financially but she couldn't find a job because the opportunities are so poor.
"She met an older man who bought her clothes, a new phone and food."
Ntethelelo's friend fell pregnant to the older man and found out she was HIV positive.
"When she went back to her place, he doesn't want her any more, he made her leave so she was traumatised and came to Whizzkids to get help."
There are multiple hurdles in halting the spread of HIV in young people in South Africa.
One is the social stigma that surrounds the virus because it can be transmitted during sex, but it can also pass from mother to child through the womb or breast milk. However, if people are on HIV medication the risk of transmitting the virus is virtually nil.
Samkelo Duma, who is 18, says he has seen this stigma first hand. "If there is a kid with HIV in school, they don't sit near her and they don't want to do anything like eat next to her since they found out."
Ensuring you stick to HIV treatment, which has to be taken daily, forever, is another challenge. As is an almost complete lack of basic knowledge handed down by parents and teachers about sex and staying safe.
Dr Madlala says there is a perception in many families that teaching about sex was giving permission to have sex. "So parents say 'stay away from boys' and as soon as you tell teenagers not to do something they'll try and do it."
Theron recalls a sex education class she sat in on at one of the programs her project supports. "We were all sitting together talking about simple stuff like how do you put on a condom and we asked if there were any questions. Nobody asked.
"The idea of raising your hand in front of your peers was just something that was never heard of."
A mother of two adopted children, Theron said families had to step up. "As a parent, ultimately honesty is the only way to go about it.
"There is nothing polite and nice about AIDS so the fact we're treating our children so politely and so nicely is problematic," she tells news.com.au. "It will kill you and like anything else that will kill your children will you not sit them down and tell them the truth about it?"
But by talking directly to young people, she says, you can see them gaining in confidence and HIV street smarts - vital tools in staying healthy.
Twenty-one-year old Slindile Memela, who goes to Whizzkids and is aiming for a career is sports management, is upbeat about changing the course of HIV.
"If we stand up and tell them what HIV is about and how to prevent it maybe they will have the mindset which is 'I will try this'. If the young people are willing to help this, why not take a chance?"
If Slindile succeeds, no one may have to fill in the heartbreaking form again.