Youth Referral - Goodwill of the Heartland

DRAFT - Youth Referral Form

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Youth Referral Form

Who is making this referral?

First, tell us about yourself and provide some contact information in case we have questions.

Name(Required)

First Last

Phone

Email(Required)

What school or agency do you represent?(Required)

What area is closest to you?(Required)

Knowing your general location helps us route this referral to the team member who services your area.

Burlington Area

Cedar Rapids Area

Clinton Area

Iowa City Area

Keokuk Area

Muscatine Area

Quad Cities Area

Who needs services?

Second, tell us about the youth you are referring for services.

Youth's Name(Required)

First Last

Youth's Current Age?

Please enter a number from 16 to 24.

This program is open to those aged 16 to 24.

Youth's Interests Include:

Select all that apply

Artificial Intelligence

Information Technology

Robotics

Manufacturing

Construction

Other

Please describe the "other" selection above.

Parent/Guardian #1 Name

First Last

Parent/Guardian #1 Phone

Parent/Guardian #2 Name

First Last

Parent/Guardian #2 Phone

Meeting Days & Time

Please tell us the best days and times to meet with the youth during the day.

Meeting Location

Where is the best daytime location for a meeting? For instance, is there a specific room at a certain school?

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