Thank you for your interest in NextGen.

Thank you for your interest in NextGen.

Please complete the below form.
Full Name*

First NameLast Name
Date of birth:*

MonthDayYear
Date
E-mail
example@example.com
Address*

Street Address

CityState / Province

Postal / Zip Code
Phone Number*
Format: (000) 000-0000.
Would you like to receive a text?*
Have you or a spouse ever served in the US military?*
Are you registered with NC Works?*
Are you currently attending school? (High School, College, GED)*
Do you have a High School Diploma or GED?*
What is your highest level of education?*
Do you identify as having a disability?*
Are you receiving SSI or SSDI?*
Are you receiving EDT, TANF, Work First, or any other benefits?*
Are you receiving Unemployment Benefits?*
Are you currently employed?*
Is your end goal employment?*
Are you pregnant or parentlng?*
If you are parenting, do you have adequate childcare? If you are not a parent, type N/A.*
Are you currently of formerly in the foster care system?*
Are you currently experiencing or at risk of experiencing homelessness?*
Do you have adequate transportation?*
Do you have any misdemeanor and/or felony charges, pending charges, dismissed charges, plea agreements, convictions, etc.?*
If you answered YES, please describe what is listed on your background.*
Are you currently on probation or parole?*
Please describe your career plan/goals to accomplish with the NextGen program:*
Please share any additional information that is helpful for staff to know:*
Referral Source (Enter who referred you to the NextGen Program. Example: Agency, school, self, etc.)*
Referral Source Contact Information (Phone number and/or Email) *If you referred yourself, enter N/A)*
Should be Empty: