YIS Needs Assessment
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.
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Email *
First Name: *
Last Name: *
Date of Birth *
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DD
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Phone Number: *
Current City and State: *
Race/Ethnicity: Select all that apply to you *
Required
Gender Identity *
Required
Sexual Orientation *
Required
Which of the following are you facing a challenge with? Select all that apply. *
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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