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Interest Form

This survey serves as an interest form as we prepare for our Y2M Project this summer. Participants must be at least 14 years old by the start of the program date.
Please note that acceptance is not guaranteed. Open enrollment began on January 31, 2022 and closes on March 15, 2022.
All applicants will receive a response to their application in April and/or May.

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* 1. First and Last Name (Mentee/Youth):

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* 2. What county do you live in?

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* 3. What is your zip code?

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* 4. How old are you? (Please note: All mentees must be at least 14 by the start of program in the summer.)

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* 5. What is your date of birth?

Date

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* 6. Do you qualify for free or reduced lunch?

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* 7. What is your race or ethnicity?

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* 8. What is your gender?

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* 9. Do you speak any other languages besides English? If so, which ones.

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* 10. Why do you want to be a part of our Y2M Project this summer?

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* 11. Are you enrolled in any other programs?

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* 12. What is your preferred method of contact?

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* 13. What is your contact information?

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* 14. Parent/Guardian Name?

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* 15. Parent/Guardian Contact Information?

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* 16. What type of access do you have available at home for virtual or remote connection?

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* 17. Do you have an Individual Education Plan (IEP) for a physical, learning or emotional disability?

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* 18. Are you currently pregnant?

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* 19. Are you a parent?

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* 20. Are you in foster care?

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* 21. Do you have a physical, mental, learning, emotional or behavioral disability?

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* 22. If you have a disability, please describe any accommodations that might help you better succeed in a career exploration program or job opportunity. We will do our best to accommodate.

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* 23. Do you currently or have you in the past used alcohol or illegal substances?

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* 24. What career areas would you be interested in or would like to learn more about?

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* 25. Have you been convicted of a crime and/or been involved with the juvenile justice system?

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* 26. Have you been convicted of a theft (misdemeanor or felony)?

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* 27. Are you now or have you ever been charged with sexual abuse or are there circumstances in your background that would call into question whether you could be entrusted with the supervision, care or guidance of children?

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* 28. Have you been convicted of Driving under the Influence (DUI)?

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* 29. Are you currently on probation?

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* 30. Will you have reliable transportation to and from our program?

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* 31. How will you get to our program during the summer?

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* 32. Do you have a valid driver's license?

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* 33. What size t-shirt do you wear?

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* 34. How did you hear about the Youth 2 Movement Program?

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* 35. All mentees 18 and under must have parent/guardian permission to participate in the Youth 2 Movement Program. If you are 18 and under you can still complete the application today if your parent is not present, however, permission must be obtained before starting our program in the summertime.

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