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E3 Power Centers Referral Form

A young person may attend the E³ Center location that is most convenient for them to access.

E³ Center City
(operated by JEVS Human Services)
112 N. Broad St., 12th Fl.
267.238.3180

E³ North
(operated by Congreso)
2800 N. American St.
267.763.8870

Youth's Personal Information

* First Name:

* Last Name:

* Age:

* Gender: MaleFemale

* Home Address:

Suite/Apt/Floor:

* City:

* State:

* Zip:

* Phone:

* Please indicate your status below: I am out of schoolI am out of workI 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 aboveSubmitting this form on behalf of someone else

Program Options

* Youth is interested in attending/transferring to the following Center/program:

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 PreparationJob Readiness TrainingPost-Secondary Bridging/College ReadinessCommunity ServiceGeneral Reading/Math Skills-BuildingWork Exposure (Internship)Life Skills ProgrammingOther:

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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