First and Last Name

Birthday

Phone Number

Email Address

What is your address?

How do you prefer we contact you? How do you prefer we contact you?Call MeEmail MeText MeNo Preference

Which Youth program(s) are you interested in learning more about? Which Youth program(s) are you interested in learning more about? Seeking Employment (16-24) GED Prep and Completion (18-24) High School Diploma Completion (14-21) Free Career Training (16-24) AmeriCorps (18-24) Youth Conservation Corps (16-24)

Are you a veteran or have you served in the military? Are you a veteran or have you served in the military?NoYesYes, disabled or homeless VeteranYes, but less than 180 days

How else can we help you? Choose as many as apply. How else can we help you? Choose as many as apply. Job opportunities, placement, career coaching, or referrals. Basic life skills and life skills needed to get and keep a job. I need support or resources for food and clothing. I need support or resources for childcare. I need housing or assistance with finding a stable place to live. I would like to work at Fiat Chrysler (FCA). I would like to attend workshops on resumes, interviewing, searching, or computer skills. I need to work on math and reading. I am interested in AmeriCorps. I am not sure, I need other support as well.

What location are you interested in? What location are you interested in? Southwest Detroit (Michigan Ave) East Side Detroit (Conner Street) Either location is fine.

How did you hear about us? How did you hear about us? Google Other Internet Search Our Website Social Media Saw a Flyer Received a Newsletter Referred by SER Metro-Detroit Other

Were you referred by a current or previous participant? If so, who?

Additional Comments