NextGen Application

1

Name* This field is required.

First

Last

2

Preferred name

3

Preferred pronouns

4

Phone Number* This field is required.

Area Code

Phone Number

5

Email* This field is required.Please use an address you check often.

example@example.com

6

Which method of communication do you prefer?

Text

Call

Email

7

In which county do you live?* This field is required.

8

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

9

Date of birth:

10

Age:* This field is required.

11

Did you complete high school or a high school equivalency program (GED)?* This field is required.

YESNO

12

Are you currently in school?* This field is required.

YESNO

13

What school do you attend and what are you studying?

14

Are you currently employed?* This field is required.

YESNO

15

Where do you work?

16

Citizenship Status:* This field is required.

17

I'm interested in...* This field is required.Please select all that apply.

Career planning

Getting into/paying for school

Finding/keeping a job

Connecting to community resources (for food, housing, clothes, etc.)

Other

18

If you selected "other", please explain below

19

Please select all that apply:* This field is required.

I, or someone in my home, receive Food Stamps or TANF.

I am pregnant or a parent.

I have a disability.

I am in or aged out of Foster Care.

I have an IEP or 504 plan on file with my most recent school.

I have a criminal history.

I did not complete high school.

I do not have stable housing.

None of the above.

20

What are your school and work goals?* This field is required.If unsure, please tell us about your passions and interests.

21

Briefly describe a recent success:* This field is required.

22

How did you hear about our program?* This field is required.

23

How did you hear about our program?