GRCCT Intake Form

We're excited to have you join our programming here at GRCCT. You or your guardian may complete the following form. 
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Parent/Guardian Information:
Gender Identity:
Female *
Male *
Non-Binary *
Transgender *
Other Gender
 
Preferred Pronouns:
She/Her *
He/Him *
They/Them *
Racial/Ethnic Identity (check all that apply):
Asian/Pacific Islander *
Black/African American *
Native American *
Hispanic or Latino(a) *
White/Caucasian *
Mixed Background *
Do you receive any of the following:
Food Assistance
Supplemental Security Income
Cash Assistance
Section 8
Medicaid
Other Benefits
 
Alternate Contact Information:
Education Information:
The following demographics are helpful in order for us to know how to best provide services, however, if you feel uncomfortable, you may choose to answer them at another time.
I am interested in (check all that apply):
Youth Build
Leadership Development
Case Management
Studying for GED
Construction Training
Customer Service Training
Job Training
Mentor
Leadership
Work Experience
One-on-One Support
Housing
Life Skills Classes
Employment Readiness Training
Other Program
Please contact us with any questions at 616-254-7736 or youthservices@bethany.org
 
We look forward to connecting with you! 
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