YIS Needs Assessment

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The purpose of this form is to collect information about you and your current situation. We may be able to provide assistance based on availability of funding and what your specific needs are.

To be eligible for assistance you must be 18 to 24 years old.

All responses are confidential.

Email *

First Name: *

Last Name: *

Date of Birth *

YYYY

Phone Number: *

Current City and State: *

Race/Ethnicity: Select all that apply to you *

Black/African American

White/Caucasian

Hispanic/Latina/Latino/Latinx

Native American or Pacific Islander

Asian

Middle Eastern

Other Race/Ethnicity

Required

Gender Identity *

Male

Female

Transgender

Non-binary

Other:

Required

Which of the following are you facing a challenge with? Select all that apply. *

Homeless

Not Homeless but Need Rent Assistance (Paid to Landlord)

Food Shortage

Medical or Mental Health Needs

Need Transportation Assistance

Need Technology for School

Need Baby Care Items

Other (Please Describe Below)

Required

Describe your current situation and why you need assistance. *

How did you find out about Youth Improvement Services? *

By submitting this entire form you confirm that all the information you provided is true and correct. A representative will contact you about your application. A receipt will be required for purchases/transactions made using funds we provide. Enter name to confirm understanding below. *

A copy of your responses will be emailed to the address you provided.

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