• Participant Registration & Intake Form

    Welcome to Core 6! Complete this form to register for one of our programs and tell us how we can support your goals. After you submit the form, a Core 6 Care Advocate will contact you to complete your enrollment.

  • Program Registration

  • Which program are you interested in?*
  • Have you participated in a Core 6 program previously?*
  • How did you hear about us?*
  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Identification Document

    A current state, government or school-issued ID is required to complete enrollment.
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  • Ethnicity*
  • Housing Status*
  • Justice System Involvement*
  • How do you plan to use your new laptop to support your goals and development? (Select all that apply.)*
  • How can we support your goals and development? (Select all that apply.)*
  • How can we support your goals and development? (Select all that apply.)*
  • Would you like to receive support from us in any of the following areas? (Select all that apply.)

  • Thank you for taking the time to complete this form. The information collected here is crucial in helping us understand the needs and experiences of the community members we serve. After submission one of our Care Advocates will reach out to validate this the information submitted and complete your intake profile and assist if you selected any support services above.
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