safelink

safelink.seamless@gmail.com

NY, US

Section 1 of 1 in this document

NeON Works: Get Connected!

Name

First Name *

Last Name *

Email *

Phone Number *

I give permission for NeON Works staff to contact me by text message in addition to phone calls

yes

no

NeON Nearest to Me *

Address Line 1 *

Address Line 2

City *

State

Zip Code (Only Eligible Zip Codes are Listed) *

Borough *

Date of Birth (MM/DD/YYYY) *

Please indicate your current age: *

Please indicate highest level of education completed

Elementary/Grade School

Middle School/Junior High School

High School

College

Please indicate your current school status

Currently in high school

Currently in HSE/GED program

Currently in college

Not currently in school

How did you hear about NeON Works?

Teacher or mentor

Family / neighbor / friend

Community organization

Website or social media

Caseworker / lawyer / probation / parole / pd

Advertising or outreach in my neighborhood

Optional: Please include secondary contact info here (name + phone and/or email) if you'd like us to reach out the person who recommended you for NeON Works, or someone we can call if we have trouble reaching you at the above listed number.

NeON Works is designed to help you reach your goals. This can include getting your HSE (GED), enrolling in college, earning vocational certifications and credentials, personal development and career exploration, money management and financial literacy, community engagement, and job and internship placements. Please tell us a little about what makes you interested in NeON Works and what you hope to get out of your participation in the program. *

disregard this