Name *

First Name

Last Name

Race *

Black / African American

Latinx

Asian/Pacific Islander/ Asian American

Caucasian/White

Native American

Multiracial

Gender *

Female

Male

Gender-Fluid/Transgender

Prefer not to say

Other

Preferred Pronouns *

She / Her/ Hers

He / Him / His

They / Them / Theirs

Phone

(###)

###

####

Parent/Guardian relation to you? *

Mother

Father

Brother/Sister

Aunt/Uncle

Grandparent

Foster Parent

other

Are you under DJS supervision or awaiting a court date? *

Yes

No

If you have an approaching court date, would you like to speak with BYA staff about writing a court letter highlighting your participation in the program? *

Yes

No

N/A

Do you have reliable internet access? *

Yes

No

Do you give BYA permission to show your work online and in a publication? *

Yes

No

Do you have a resume? *

Yes

No

Do you have a cover letter? *

Yes

No

Which of the following identity documents do you have:

School ID

Driver's License/Gov't ID

Passport

Report Card

Hospital Record

Which of the following work authorization documents do you have:

Birth Certificate (Copy or Original)

Social Security Card (Copy or Original)

Green Card