2. Agency Name*
4. Agency Address*
6. City*
7. State*
8. Zip*
10. Agency Telephone*
11. Agency Fax
13. Agency Website
15. Contact Person for Agency*

    Please include the person’s title

17. Direct Contact Information for Contact Person
19. Telephone Number *
20. Email Address*
22. Description of organization:*
23. Anticipated goal of program:*
25. Please list the duties the youth will be assigned to perform: *
27. Start and End Date of Program*
    Start and End Date of Program Start Date

    —

    Start and End Date of Program End Date
28. Hours of Operation for Organization*
30. Number of Hours to Be Completed*
32. Clients Served*

    1. Male
    2. Female
    3. Youth between Ages (13-17)
33. Focus of program*

    1. Academic
    2. School to career
    3. Youth development

    select all that apply

35. Does your organization offer job/career opportunities to youth after they have completed the program?*
    -- Select One --YesNo
37. Has any employee or staff member been convicted of a sex offense?*
    -- Select One --YesNo
39. Does your agency provide background checks for all of your employees?*
    -- Select One --YesNo
41. What type of supervision will be provided? *
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit

* indicates a required field