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Interest/Referral Form for Young Adult Programs at MN Valley Action Council
Thank you for your interest! A representative from MN Valley Action Council for your service area will contact you with more information upon completion of this form.
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* Indicates required question
What County do you live in?
*
Blue Earth
Brown
Faribault
Le Sueur
Martin
Nicollet
Sibley
Waseca
Watonwan
Other:
First and Last Name
*
Your answer
If you answer "YES" to any of the following items OR are interested in more information, please continue filling out this form and someone will reach out to you shortly regarding which programs you may be eligible for! (Income guidelines apply for some programs) Check all that apply
*
I struggle with reading or math
I (or my parents/family) receive public assistance (SNAP; MFIP; etc ) or I receive Free/Reduced Lunch at School
I have a disability, IEP or 504 plan
I am one or more grades below others my age in school and/or need Credit Recovery
I am in, or have been in, foster-care, foster home, or out of home placement
I am chemically dependent and/or a child of chemically dependent parents
I have a criminal background or am working with probation
I am pregnant or am a parent/parenting
I want to obtain a credential/ or am interested in education beyond High School.
I am currently enrolled in an education program (college, a training course, etc)
Other:
Required
Date of Birth
*
MM
/
DD
/
YYYY
Phone Number
*
Your answer
Email
*
Your answer
What is your mailing address? (Street/Po Box, City, State, Zip)
*
Your answer
What are the best ways to reach you? (Choose all that apply)
*
Phone Call
Text
Email
Mail
Required
Do you need an interpreter? If yes, what language
*
No
Yes- please list your preferred/needed language on the line below
Other:
Required
What services are you interested in?
*
"Get Started" Program
Work Experience Or Internship
GED/Adult High School Diploma Support
Career Exploration
College/Post-Secondary Education (If you know what type of training, please also select "other" and list your interest area)
Other:
Required
Who is filling out/submitting this form?
*
Self
Parent/guardian
Case manager
Social Worker
Counselor
Teacher
Therapist
Other:
If you need assistance with this form, contact Sarah McDonald at 507-345-2439. If no assistance is needed, please 'submit' below and someone will be in contact with you soon!
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