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CeJay Cares Programs Application
Please fill in the below information to become an applicant for our programs.
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Today's Date
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Person Participating First Name
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Your answer
Person Participating Middle Initial
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Your answer
Person Participating Last Name
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Your answer
If this is an application for a child, please provide the parent/guardian's full name below:
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Select Program
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Choose
WOMB (Women of Massive Belief) Initiative
GIRL (Growing Into Respectable Ladies) Initiative
FuelMan Initiative (Youth Males)
Special Assistance
Please provide your full address (Street, City, State, and Zip Code)
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Please provide the person participating email address.
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Please provide the person participating home phone number.
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Please provide the person participating mobile phone number.
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Please provide the person participating phone number.
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Please provide the person participating race.
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Please provide us with the person participating gender.
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Please provide the person participating age
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Please provide the person participating date of birth.
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If you are the applicant's parent, please provide us with your name and contact information (phone and e-mail)
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If you are in school, please provide us with your school name, counselor, and grade
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Who referred you to our programs?
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