YWCA -ETC Interest Form

Date

MonthDayYear
Date
Parent/Guardian
Parent/ Guardian's First Name
M.I.
Parent/ Guardian's Middle Initial
Last Name
Parent/ Guardian's Last Name
Parent/Guardian DOB:

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Zip Code
Primary Phone Number
Additional Phone Number
Is it okay to contact me via text message

yesno
Email
example@example.com
I have a child in the home under the age of 18

YES
Preferred Language
Interest In Services
I am interested in working with a mentor for these services (check all that apply)

Career PlanningFamily Health & WellbeingHousing StabilityFinancial Literacy/ BudgetingEducation AdvancementGoal Setting
Who would you prefer serve you through the East Tennessee Collaboration?

YWCA Knoxville & the Tennessee ValleyBoys and Girls ClubKnox Area Urban LeagueCatholic CharitiesCentro HispanoYMCAGirls, Inc.Good Neighbors of Blount Co.United Way of AndersonNo Preference
Are you or a family member an employee at United Way of Greater Knoxville or one of the above agencies?

yesno
If yes, which agency?
Who is submitting the referral?
Self-referral
Include all information
The Change Center
Include all information
Agency, Contact Person & Phone Number
Include all information
Friend/Family & Phone Number
Include all information
Other
Include all information
Contact person
Phone
Phone
*Please completed form before submitting. Questions?

Contact one of our ETC Mobility Mentors:

Knox:

Tonya Clark- tclark@ywcaknox.com or 865-216-6648

Anderson:

Kelli Monk- kmonk@ywcaknox.com or 865-680-6078

Multi-County (Knox, Sevier, Blount)

Becca Pace- rpace@ywcaknox.com or 865-640-6193

Multi-County (Knox, Roane, Loudon)

Deanna Lemons- dlemons@ywcaknox.com or 865 679 0601
Should be Empty: