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Youth Connections Survey
Use the form below to tell us about your interest in the Youth Connections Program.
Who is Completing this form
(*)
Who is Completing this form
Youth
Adult
Both together
Please indicate who is submitting this form
Age of Youth
(*)
Age of youth is required
Name(s)
(*)
Please let us know your name.
Home Address
(*)
Address is required
Your Email Address
Please let us know your phone number or email address.
Phone
Please let us know your phone number or email address.
Check the types of programs you or your son or daughter would like to participate in:
(*)
Check the types of programs you or your son or daughter would like to participate in:
Community Events like Culture Night, Game Night, Block Party or Movie Screenings
Literacy Programs like Reading, Book Club, Tutoring for younger children
Classes like Money Management, College Prep (ACT/SAT), Small Business Training
Information Fairs like Youth Fairs, Career and Job Fairs
Tech Programs like Robotics and Code Club
Arts Programs like Music, Creative Writing, Video Production, Poetry
Please choose programs of interest
Please add other ideas if they are not included above:
Invalid Input
Would you or your son or daughter be willing to volunteer as part of the planning committee?
Would you or your son or daughter be willing to volunteer as part of the planning committee?
Yes
No
Invalid Input
What day/s of the week work best?
(*)
What day/s of the week work best?
Monday
Tuesday
Wednesday
Thursday
Friday
Please indicate days you can be reached
What time/s? Check all that apply
(*)
What time/s? Check all that apply
9 - 11 a.m.,
11 a.m. - 1 p.m.,
1 - 3 p.m.,
3 - 5 p.m.,
Please indicate times you can be reached
Are you willing to work as a mentor in children’s programs?
(*)
Are you willing to work as a mentor in children’s programs?
Yes
No
Are you willing to be a mentor
Do you want resources for post-secondary education, employment or training?
Do you want resources for post-secondary education, employment or training?
Yes
No
Invalid Input
Any questions?
Invalid Input
May PHA use your information to contact you about programs?
May PHA use your information to contact you about programs?
Yes
No
Invalid Input
Signature
(*)
Signature
By checking this box, you confirm that PHA can use this information to contact you.
Please indicate that you agree with form submission
Submit
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Section 3
