Goodwill SWPA - Youth Information Request Form

We can help you get a job and more! We offer support services to help with transportation and any other barriers you are facing.

* First Name:

* Last Name:

What is your preferred name?

What are your preferred pronouns?

* Age:

* Zip Code:

Email Address:

* Phone Number:

* Do you have your high school diploma or equivalent degree (GED, HiSET)?

Yes

* What is your preferred method of communication?

Phone Call

Text

Other :

* Have you been involved with the justice system? Note: This does not disqualify you from participation.

Yes

I want to enroll in community college or a university.

I need to get my GED.

I want to change jobs or career paths.

I need a second chance after involvement in the justice system.

Other:

* How did you hear about us?

If you are from an organization that is referring a youth, please list your name and organization:

* required