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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 *

Last Name *

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

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)

Birthdate *
mm/dd/yyyy (example: 01/15/1999)

Do you have a high school diploma? *
Yes No

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

Are you presently enrolled in High School? *
Yes No

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

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.

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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