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Email
*
Your email
Personal Information
Last Name
*
Your answer
First Name
*
Your answer
Birth Date
*
MM
/
DD
/
YYYY
Address
*
Your answer
City
*
Your answer
State
*
Your answer
Zip Code
*
Your answer
Phone Number
*
Your answer
Email
*
If none write none
Your answer
What country are you from?
*
Your answer
Date of US Settlement
*
This is the date when you came to live in the USA. If you can't remember the exact date please guess to the nearest year.
MM
/
DD
/
YYYY
Citizenship status
*
Residency status not reported to New York State
US Citizen
Immigrant
Refugee
Other:
Social Security number
*
If none please write none
Your answer
Gender
*
Male
Female
Non-binary
Prefer not to say
Other:
Race/Ethnic Identity
*
Native Hawaiian
Native American
Alaskan Native
Asian
Pacific Islander
African American
Afro-Caribbean
African
Latino/a
White
Other:
Required
Have you ever been convicted of a felony?
*
Your answer has no effect on your ability to attend our program
Yes
No
Do you Smoke?
*
Your answer has no effect on your ability to attend our program
Yes
No
Emergency Contact Name/Relationship
*
Your answer
Emergency Contact Phone number
*
Your answer
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