AMP Interest Form

Teen Life Coaching

INTEREST FORM
LEVEL UP TODAY!

Are you 16-24 years old?

Ready to get on your path to success?

TEEN LIFE COACHING can help YOU!

The Teen Life Coaching program connects you with a success coach, who will connect you with resources to help you gain the skills, knowledge and employment opportunities you need to get to your next level.

AMP is funded by the Franklin County Board of Commissioners, the Workforce Development Board of Central Ohio and is administered by FCDJFS. *Participants must meet income eligibility requirements.
YOUR NAME*

First NameMiddle NameLast Name
Referred by: (Enter full name, if applicable)
Birth Date*

MonthDayYear
Date
Birth Date*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What school are you attending?
If your school is not on the list, put it below
E-mail*
example@example.com
Phone Number*
Are you eligible to work in the United States? *

YesNo
Are you eligible to work in the United States?*

YesNo
Are you eligible to work in the United States?*
Do you live in Franklin County?*

YesNo
Do you live in Franklin County*
By my submission, I am expressing interest in the Teen Life Coaching Program offered by CLC. I understand that a representative from CLC will be contacting me to review my eligibility for this program.
Please provide any information that can help us better serve you
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Teen Life Coaching