Youth Excellence Project Interest Form

Please use this form to refer a youth to our program. Note that while we are still determining our 2024 cohort, we anticipate that some youth will need to be placed on a waiting list or may be limited to participating in certain activities. However, we are very interested in hearing from you and setting up a time to talk. 

Once your response is submitted, we will be in with the youth's guardian by email to set up a phone or Zoom meeting. 
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Your Name *
Your relationship to the youth *
Your phone number  *
Your email address *
Youth's Full Name *
Youth Date of Birth
MM
/
DD
/
YYYY
Youth Racial Ethnic Background (check al that apply) *
Required
Which best describes the youth's living circumstances? *
What is the youth's current grade level? *
Caregiver/Legal Guardian Name(s) *
Caregiver phone number(s) *
Caregiver email address(es) (if known)
Youth's Mailing Address
DCF Involvement? *
IF YES to current DCF then provide name and contact information for DCF caseworker. 
Does the youth have any of the following conditions? (check all that apply) *
Required
Does the youth have a history of the following? (check all that apply) *
Required
Which of the following outdoor activities has the youth participated in? (check all that apply) *
Required
Use this space to describe the youth and any other information that might indicate whether he is a good fit for the program.  *
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This form was created inside of Outside Perspectives.