YOUTH INTEREST FORM
This is a program specifically for Alabama youth ages 16-24 that are facing barriers to education and good employment.
Barriers Include: Foster Care (current or previous); Homelessness; Runaway; Pregnant or Parenting; High School Drop-Out; Current or past involvement with criminal or juvenile justice system; English second language learner; Person with disability; Basic skills deficiency; Migrant Youth or member of migrant family; Public Assistance; etc.
Name
First Name
Last Name
Email
example@example.com
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
How old are you
Does any of these circumstances apply to you?
Parent(mother or father) or Pregnant
Receives Public Assistance
Foster Care (Current or Past)
Homeless
Disability
Prior contact with the law, Arrest, or Juvenile Justice Case
What city is nearest to you?
Montgomery
Birmingham
Gadsden
Demopolis
Counties near Montgomery
Montgomery
Macon
Russell
Lee
Chambers
Bullock
Counties near Demopolis
Marengo
Sumter
Greene
Hale
Bibb
Counties in Gadsden
Etowah
Cherokee
Other
Counties near Birmingham
Chilton
St. Clair
Blount
Walker
Shelby
What is the best way to contact you
E-mail
Text
Phone Call
Are you currently enrolled in school?
Yes, enrolled in high school
Yes, enrolled in college or technical program
No, I graduated from high school
No, I did not complete high school
What programs are you interested in?
Work - Experience
Work Readiness Training
Credential Training
Unsure
Submit
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