Please complete and submit the questionnaire below and we will call and/or email you to further determine eligibility. The completed questionnaire is confidential and will be reviewed and evaluated by staff only. 

Note: Our program is full, but please fill out the questionnaire if you are interested in participating!
          Program enrollment will resume on July 1, 2018 for out of school youth ages 16-24. 

Preliminary Youth Eligibility Questionnaire

Date *
Date
How did you hear about us? *
Name *
Name
Address *
Address
Mobile Phone *
Mobile Phone
Home Phone
Home Phone
• Basic Skills Deficient • Disabled • English is a Second Language (ESL) • Family Violence • Foster Youth • Gang Involved/At Risk • High School Drop-Out • Homeless/Runaway • Individual Education Plan (IEP) • Offender • Pregnant/Parenting