Bird Street Community Center's Social Justice & Violence Intervention Virtual Program Sign-Up
Due to the pandemic we will shifting our program efforts to a virtual format since we cannot use our space to conduct our regular programming. If this sounds like something you would be interested please fill out the information down below. Youth will be awarded gift cards upon completion of the program.

Please contact Jamel Langston with any questions that may arise.
Email address *
Your Name (First, Last) *
What School Do you attend? *
Current Grade *
email address *
What day would work best for you to participate in our virtual program so we can have a sense on scheduling? *
what times would work best for you? *
Parent/Guardian *
Parent/Guardian Phone Number *
Parent/Guardian Email
Emergency Contact *
Emergency Contact Phone Number *
Comments and/or questions
Never submit passwords through Google Forms.
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy