Cycles to Wings Caterpillars Pilot Interest Form 🦋✨
Share your contact details and preferences so we can update you when program details and enrollment are available.
Parent/Guardian Full Name
*
First Name
Last Name
Parent/Guardian Email
*
example@example.com
Parent/Guardian Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Preferred Contact Method
*
Email
Phone call
Text message
City
*
ZIP Code
*
Chicago Neighborhood
Young Person's First Name Only
*
Young Person's Age
*
Please Select
12
13
14
15
Current Grade
*
Please Select
6th
7th
8th
9th
10th
11th
12th
School Name
Areas of Interest (Select all that apply)
Self-confidence and identity
Mental wellness and coping skills
Life skills
Financial literacy
Healthy relationships and safety
Career exploration and entrepreneurship
Leadership and community service
Creative activities
Other
If Other, please describe
Scheduling Preference
*
Weekday after school
Saturday
Either
Would transportation assistance affect her ability to participate?
Yes
No
Not sure
What would you hope she gains from the Caterpillars Pilot?
How did you hear about Cycles to Wings?
Please Select
Website
Social media
Friend or family
School
Community organization
Event
Other
Submit
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