Core 6 Participant Information Form

Core 6 Participant Information Form

How will we use this information? We use this data to demonstrate the diversity and specific needs of our community. By providing this requested information below, you enable us to secure funding and enhance our programs to directly address and support your needs. Your responses will remain confidential and will only be used for program development, reporting, and funding purposes. Your participation ensures that we can continue to advocate for and provide resources that truly make a difference.
Your Name
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
SMS Opt-in

By checking this box, you agree to receive text messages from Core 6 related to (program details, case management and events). You may reply STOP to opt-out at any time. Reply w/ "HELP" to (619) 308-6595 for assistance. Messages and data rates may apply. Message frequency will vary
Program Registration
Which program are you interested in?*

Core 6 - Entrepreneurship ProgramFLIP - Financial Literacy Investment ProgramElevate Youth Leadership Program (12yr-26yr)Culinary on the Job Training (OJT)Other
How did you hear about us?*

Social MediaFriend or Family MemberCommunity Event / FlyerProbation / Parole OfficerOther
Ethnicity*

American Indian/ Alaska NativeAsianBlack or African AmericanHispanic/ LatinoNative Hawaiian/ Pacific IslanderWhite CaucasianMore than one race/ ethnicityOther
Gender*
Educational Attainment*
Housing Status*

Stable HousingUnhoused (outside, in car)ShelterTransitional HousingLiving in permanent supportive housingOther
Justice System Involvement*

No justice system contactArrestedConvicted of a crimeIncarcerated for 30 days or moreOther
How do you plan to use your new laptop to support your goals and development? (Select all that apply.)*

Continuing my education (e.g., online courses, research, or assignments)Advancing my career (e.g., job applications, skill-building, or remote work)Managing personal finances (e.g., budgeting, credit improvement, or tax preparation)Advancing my business or organization (e.g., marketing, ecommerce or administration)
How can we support your goals and development? (Select all that apply.)*

Continuing my education (e.g., online courses, research, or assignments)Advancing my career (e.g., job applications, skill-building, or remote work)Managing personal finances (e.g., budgeting, credit improvement, or tax preparation)Advancing my business or organization (e.g., marketing, ecommerce or administration)
What are 3 goals you would like to accomplish in the next 3 months?*
We are here to support your goals!
Would you like to receive support from us in any of the following areas? (Select all that apply.)

Case Management: Personalized support to help you achieve your unique goals.Mental Health Therapy Sessions: Confidential sessions with licensed professionals to prioritize your emotional and mental well-being.Tax Preparation Assistance: Guidance to ensure accurate and stress-free tax filing.Credit Counseling: Tools and resources to help you understand and improve your credit.Other Financial Supportive Services: Access financial support and resources to help you reach your personal, business and financial goals.
Upload a copy of your State, Government or School Issued ID*

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Thank you for taking the time to complete this form. The information collected here is crucial in helping us understand the needs and experiences of the community members we serve. After submission one of our Care Advocates will reach out to validate this the information submitted and complete your intake profile and assist if you selected any support services above.
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Core 6 Participant Information Form

Program Registration

We are here to support your goals!