Continual Care

Rochester Youth Organizer Pre-Application

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Applicant Name

Identify the primary applicant

Salutation:

None

First:*

Middle:

Last:*

Suffix:

Date of Birth:

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Teen Empowerment
Rochester, New York

Teen Empowerment General Pre-Application

Preferred Name (name you'd like us to call you, if different)

Social Media Name/Site

Which part of town do you live in?

--Select--

Where do you live closest to in your neighborhood?

--Select--

How did you find out about this job? (If flyer, where?)

Have you ever been involved with Teen Empowerment before?

Yes

What are the best ways to contact you? (Check all that apply)

Text

Phone

FB Messenger

FaceTime Audio

Request Programs

Roc- Eastside (NE)	Roc- Northside (NW)	Roc- Reconnections
Roc- Westside (SW)

Applicant Contact Information

Email:

Phone:

Alternate Phone:

Address 1:	Address 2:
City:	State: New York --Choose One-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	County: --Choose One-- --Choose One-- Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings Kings (Brooklyn) Lewis Livingston Madison Monroe Montgomery Nassau New York New York (Manhattan) Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond Richmond (Staten Island) Rockland Saint Lawrence Saratoga Schenectady Schoharie Schuyler Seneca St. Lawrence Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates	ZIP code:

School Information

Identify the school that you are enrolled in

--Select One--

Enter your grade:

--Select One--

Demographics

Gender Identity: --Select One-- --Select One-- Female Male Non-Binary Other	Race: --Select One-- --Select One-- American Indian or Alaska Native Asian or Asian American Black or African American Latino/a or Hispanic Middle Eastern or North African Native Hawaiian or Pacific Islander White or European American Multiracial / Two or more races (SPECIFY BELOW) Other Declined . . . . . . . . . . .	Ethnicity: --Select One-- --Select One-- Afghan Akwesasne/Mohawk Arab Black or African American (non-Hispanic) Brazilian Cape Verdean Caribbean / West Indies Chinese Congolese Cuban Dominican Egyptian French German Ghanaian Haitian Haudenosaunee Irish Italian Jamaican Kurdish Lebanese Mashpee Maya Mexican Moroccan Nepalese Nigerian Norwegian Onondaga Other Pakistani Panamanian Portuguese Puerto Rican Scandinavian Scottish Seneca Nation Somali South Asian Indian Spaniard Sudanese Swedish Syrian Trinidad/Tobago Ukrainian Vietnamese Wampanoag West Indian (non-Hispanic) Yemeni .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. .. Afro-Latino/a/x Asian/Asian American Central American Hispanic or Latino/a/x Middle Eastern Mixed/Multiethnic Native American/Indigenous
Sex Assigned At Birth: --Select One-- --Select One-- Female Male	Living Arrangements: --Select One-- --Select One-- N/A	Household Types: --Select One-- --Select One-- N/A

Marital Status:

--Select One--

Primary Language:
English Choose Clear

Guardian Information

Name:
Email:	Phone:

Address 1:	Address 2:
City:	State: New York --Choose One-- Alabama Alaska American Samoa Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	County: --Choose One-- --Choose One-- Albany Allegany Bronx Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Columbia Cortland Delaware Dutchess Erie Essex Franklin Fulton Genesee Greene Hamilton Herkimer Jefferson Kings Kings (Brooklyn) Lewis Livingston Madison Monroe Montgomery Nassau New York New York (Manhattan) Niagara Oneida Onondaga Ontario Orange Orleans Oswego Otsego Putnam Queens Rensselaer Richmond Richmond (Staten Island) Rockland Saint Lawrence Saratoga Schenectady Schoharie Schuyler Seneca St. Lawrence Steuben Suffolk Sullivan Tioga Tompkins Ulster Warren Washington Wayne Westchester Wyoming Yates	ZIP code:

Other Information

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