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Career & Education Interest Form
Thank you for your interest in Career and Education programs at Cypress Hills Local Development Corporation. A staff member will follow up with you in a few days.
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* Indicates required question
Are you completing this form for yourself or is this a referral?
*
I'm completing this form for myself
I am referring a client
If you are referring a client, please type your full name, title, agency and contact information below
Your answer
How did you hear about us?
*
CASES
Commonpoint Queens
CHLDC-Staff
DYCD Website
Facebook
FedCap
Flyer
Friend/Relative
Instagram
Unity Works
Word of Mouth
Other:
First Name
*
Your answer
Middle Name
Your answer
Last Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Current Age
*
Your answer
Phone Number
*
Your answer
Email Address
*
Your answer
Zip Code
*
Your answer
Are you proficient in the English language?
*
Yes
No
Are you authorized to work in the United States?
*
Yes
No
Are you currently working?
*
Yes
No
Are you currently in school?
*
Yes
No
If yes, what school are you currently enrolled in?
Your answer
When are you graduating? (Month/Year)
Your answer
Do you have access to a working desktop or laptop and Wifi?
*
Yes
No
What credentials do you have? (Check all that apply)
*
High School Diploma (do not select if you have not yet graduated)
IEP Diploma
High School Equivalency Diploma (formerly GED)
Associate's Degree
Bachelor's Degree
Other:
Required
Do you receive SNAP benefits?
*
Yes
No
I don't know
What age range do you fall under?
*
16-24 years old
25 and up
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