Continual Care

Optional--Choices will appear only if you select 'yes' to the following questions:

Did you want to share multiple races?

--Select--

Did you want to share multiple ethnicities?

--Select--

Are you fluent in multiple languages?

--Select--

Teen Empowerment General Pre-Application

Nickname or Preferred Name

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

Have you ever been involved with Teen Empowerment before?

--Select--

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

Text

Phone

Email

FB Messenger

FaceTime Audio

Request Programs

Choose just ONE program based on where you live or have the closest connection.

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

Applicant Contact Information

Please also provide a 2nd "alternative" phone # (parent or other backup where we can reach you).
Choose first the "Community" & then the "Neighborhood" where you live closest to.

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: Monroe --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:

Community:

--Not Specified--

Neighborhood:

--Not Specified--

Applicant Name

..

Salutation:

None

First:*

Middle:

Last:*

Suffix:

Date of Birth:

Open the calendar popup.

School Information

..

Identify the school that you are enrolled in

--Select One--

Enter your grade:

--Select One--

Demographics

..

Gender Identity:

--Select One--

Race:

--Select One--

Ethnicity:

--Select One--

Primary Language:
English
Choose Clear

Other Information

Enter as much information below as possible.

Social media

Social media name(s)

(Text)

Social media platforms

Which socials you use (Text)

Instagram

Tik Tok

SnapChat

Facebook

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