Advanced Training Interest Form Medical 
This form is for youth participants interested in medical training between the ages 16-24*. 
Please make sure you meet the requirements before continuing with the form. 

The following trainings are free and funded by the Department of Youth & Community Development. Our next classes will be starting January 2025! 

**Samuel Field YM & YWHA-Commonpoint is an equal opportunity employer/program. Auxiliary aids and services are available upon request to individuals with disabilities.**
Email *
Eligibility Requirements - These are the program eligibility requirements set by the DYCD Program. *
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I am aware that I am applying for the Queens location *
Last Name *
First Name *
What gender pronouns do you identify with: *
Write your date of birth mm/dd/yyyy 
*Please remember for this program you have to be between the ages 18-24*
 *
Please enter a phone number to reach you at: *
Please write your FULL Address - make sure to include Apartment number and Zip code *
Which NYC borough do you currently live in (required) *
Are you currently working? *
Will you be employed at your current job in the Spring 2026 ? (put N/A if you are unemployed) *
Are you looking for employment in the medical field? *
Are you able to complete 150-250 hours of paid internship during the course of the program? *
What is your highest level of education? *
Please write the High School you last attended *
Please write the year you graduated High School or received your GED *
Are you enrolled in college classes?  *
Which program are you most interested in?  *
What is the best way to contact you?
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How did you hear about this program? *
Required
Do you currently receive SNAP benefits? *
Are you a Legal Guardian/Parent? *
Will you be requiring a HRA referral for child care supports in order to attend classes or internship? *
All classes will be in person in Queens. Are you willing to commute to Queens for In-person classes? *
Please check all that apply to you *
Required
Are you able to read and write in English?
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If you are vaccinated, which vaccine did you receive? *
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