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HARVEST MANOR (SATELLITE OFFICE) GRAND OPENING
Fill out the form below to Pre-Register for the Opening
Parent Name
First name/Primer nombre
Last Name/Apellido
Which Youth program(s) are you interested in?
Choose available Options
Youth Programs
001 - Mentoring Groups
002 - Tutoring
003 - Entrepreneurship/Business Leadership
005 - STEM Technology
006 - KREW12 - Digital Media
007 - Personal Development/Mental Health Wellness (SEL)
008 - Counseling
009 - Conference Events
Adult Programs
101 - Workforce Assistance/Job Fairs
102 - Adult Computer Literacy
103 - Business Leadership Development
104 - Connection to Wraparound support (basic needs, etc.)
105 - Counseling (Mental Health, Substance etc.)
106 - Trauma Informed Care Service/Training
107 - Parenting Program
108 - Positive Adult Support Programs/Events
109 - Other
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Parent or Guardian Name
First name/Primer nombre
Last Name/Apellido
Email
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Zip Code
Street Address
Street Address Line 2
City
State / Province
Enter your Postal Code
Student Date of Birth
-
Month
-
Day
Year
Date Picker Icon
Homeless (no permanent zip code)
*
Yes
No
Family Size
*
Please Select
Select an Option
1
2
3
4
5 or more
Choose One
Information about Additional Children
I am self-declaring my identity as proof of identification at this time:
*
Do you give AAYHF permission for you or your child to be photographed, filmed, audio-taped or videotaped at AAYHF events?
Yes
No
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Ethnicity
*
Please Select
Hispanic or Latino
Non-Hispanic or Latino
Choose One
Race
*
Please Select
American Indian / Alaska Native
Asian
Black / African American
Native Hawaiian / Pacific Islander
White
Some other race
Two or more races
Unspecified
Choose One
Gender
*
Please Select
Female
Male
Identify as Transgender
Unspecified
Choose One
Age
*
Please Select
Under 5
5-11
12-14
15-17
18-24
25-39
40-54
55-64
65-74
75 and over
Choose One
Estimate Household Annual Income:
*
I certify that I currently receive the indicated income from the following source:
*
Are you a robot?
*
Submit Application
Should be Empty: