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E3 Power Centers Referral Form
×
A young person may attend the E
3
Center location that is most convenient for them to access.
E
3
Center City
(operated by JEVS Human Services)
112 N. Broad St., 12th Fl.
267.238.3180
E
3
North
(operated by Congreso)
2800 N. American St.
267.763.8870
Youth's Personal Information
* First Name:
* Last Name:
* Age:
* Gender:
Male
Female
* Home Address:
Suite/Apt/Floor:
* City:
* State:
--please choose--
Pennsylvania
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
* Zip:
* Phone:
* Please indicate your status below:
I am out of school
I am out of work
I am involved with the court system
* How long have you been out of school?
Next Court Date:
Formatted: YYYY-MM-DD
* I am:
The youth contact listed above
Submitting this form on behalf of someone else
Program Options
* Youth is interested in attending/transferring to the following Center/program:
Locations
E3 Center City:
(112 N. Broad St., 12th Fl.)
E3 North (formally E3 Girard):
(2800 N. American St.)
Youth is interested in (check all that apply):
GED Preparation
Job Readiness Training
Post-Secondary Bridging/College Readiness
Community Service
General Reading/Math Skills-Building
Work Exposure (Internship)
Life Skills Programming
Other:
Documentation
I understand that youth applicant will be asked to produce a Driver's License or State ID, Social Security Card, and/or Birth Certificate.
Notes
Notes:
Submitter's Information
* Full Name of Submitter:
* Submitter's Email:
* Submitter's Phone
Submitter's Title:
Submitter's Agency/Office:
Submitter's Fax
PYN, Inc.
Address:
400 Market St.
Suite 200
Philadelphia, PA 19106
Email:
info@pyninc.org
Landline:
267.502.3800
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