Mercy Connections

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Mercy Connections

PRE-REGISTRATION FORM

Using the information you share with us in this form, a Mercy Connections staff person will contact you. At that time, if the program(s) you identify below seem to be a good fit for your needs and interests, and if there is space available, we will talk about next steps to finalize your enrollment.

Today's Date

YYYY

Your name *

Your phone number

Your email address

Date of Birth

YYYY

Gender

Ethnicity:

White/Caucasian

Hispanic

Asian

Black or African American

Native American

Other:

Clear selection

Place of Origin or Nationality

First Language

Other Languages spoken

Your mailing address

What is the best way to reach you?

Phone

Mail

Other:

Clear selection

Which program(s) are you interested in registering for?

Setting Course for 2022, Mondays December 6 and 13, 10am to 12pm

Pens & Pages

MAP!- Make an Action Plan

Developing Self, Mondays & Wednesdays 10 AM-Noon

Circle, ongoing, Thursdays 11 am-12 pm

Academic Tutoring

U.S. Citizenship Test Preparation, Zoom

U.S. Citizenship Test Preparation, In Person

Vermont Community Leadership Training

How did you find out about the program(s) you are interested in?

Briefly let us know why you think the program(s) may be right for you.

Please let us know if you have any specific questions.

THANK YOU FOR YOUR INTEREST!

Please double check all your answers above for accuracy and submit this form. Someone from Mercy Connections will be in touch.

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