2. Name of Organization
3. Point of Contact
5. Address
7. City
8. State
9. Zip Code
11. Phone Number
12. Tax ID Number
14. Type of Organization
15. Number of Positions Available
17. Located in County

    1. Yes
    2. No
19. Notes
21. Work Sites
    Please provide information on various work site(s) that youth may be assigned, if available.
23. Address
25. City
26. State
27. Zip Code
29. Number of Positions
31. Brief Description of Type of Work to Be Assigned
33. Secondary Worksite Information
35. Address
37. City
38. State
39. Zip Code
41. Number of Positions
43. Brief Description of Type of Work to Be Assigned
45. Youth Qualifications
    Please provide information on preferred qualifications/skills/age of youth assigned to each site, if available.
47. Preferred Age Range
48. Total Number of Youth Your Agency Can Accommodate
50. Preferred Skills
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52. 1. Receive an email copy of this form.
53. Email address

    This field is not part of the form submission.

54. Submit

* indicates a required field