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2. 
4. Eligibility Criteria

   Low-income youth between the ages of 15-19 that reside in the City of Petersburg whose family income does not exceed 125% of the established Federal poverty guidelines, who receive TANF, SNAP, Medicaid or Free/Reduced Lunch.

6. Name*
7. Ward #*
   -- Select One --1234567Don't Know
9. DOB*
   DOB
10. Age
11. Gender
    -- Select One --MaleFemale
13. SSN*
14. Best Contact Number*
16. Address1*
18. Address2
20. City
21. State
22. Zip
24. Email Address*
25. School*
27. Do you have work or volunteer experience?*

    1. Yes

    1. No
29. If Yes, Where?
31. Have you participated in the Summer Youth Employment Program in the past?*

    1. Yes

    1. No
33. If Yes, When:
35. Does your family recieve:*

    1. Medicaid

    1. SNAP

    1. TANF

    1. Don't Know
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit

* indicates a required field