Program Sign Up Form

Programs and Services Interest Form

Fill out this form for the programs/ services you are interested in and a staff member will follow up with you.
NOTE: Please fill out a separate form for each indivdual person in your household that is interested in our programs.
Name*

First NameLast Name
Date of Birth

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

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Which Khmer Maine programs and services are you interested in?*

Traditional Khmer Dance ClassesFood and Farm 4-H Program for YouthElder Health and Wellness ProgramLand and Justice Outdoor Program (for adults, youth, and elders)English Language Acquisition - Book Buddy GroupCitizenship Classes (civics test and interview prep)Sports-related programs (basketball, soccer, etc.)
Should be Empty:

Programs and Services Interest Form