Interest Form

Civicorps > Engage > Apply > Interest Form

Sign Up Now to Start Our Program! – Take the first step on your journey with Civicorps!

Fill out this form and a member of our team will contact you to get started.

First Name *
* First Name is Required

Last Name *
* Last Name is Required

Phone *
What is the best number to reach you?. Please enter numbers only in format 9999999999.
. * Phone Number is Required

The number is...
My Cell Phone My Home phone (landline) A friend or relative's cell phone A friend or relative's home phone (landline) Other:

Email (optional)
* Enter valid Email Address

Birthdate *
mm/dd/yyyy (example: 01/15/1999)
* Date of Birth is Required * Date of Birth in format MM/DD/YYYY

Do you have a high school diploma? *
Yes No * Required - please select an option

If No, What is the highest grade level you have completed?

Are you presently enrolled in High School? *
Yes No * Required - please select an option

Last High School Attended (Enter current high school if presently enrolled above):

If Last High School Attended is not in the list above, please enter it here:

Do you have a driver's license? *
Yes No * Required - please select an option

Which program are you interested in signing up for today? (select all that apply):*

Academy high school

Conservation internship

Recycling apprenticeship

Not sure. I would like to learn more.

* Please check at least one Program Interest!

Have you ever attended Civicorps before? *

Please fill out the following Return Request:
What dates were you in Civicorps?
Why did you leave?

How have you overcome the obstacle(s) that prevented your progress the first time?

What do you hope to accomplish if you are allowed to return?

What is your Preferred Language? ¿Cuál es su idioma preferido?

How did you hear about Civicorps?

If a person referred you please enter their name:

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