Name *

First Name

Last Name

Best number to reach you at *

(###)

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Parent Name *

First Name

Last Name

Parent Phone Number *

(###)

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Do you accept your spot in Groundwork Bridgeport's Urban Fellows Program? *

Yes

No

Will you be able to attend the info session for the Urban Fellows Program on Wednesday, December 5th at 5:00 pm. The info session will be held at 1001 Main Street, Suite 18, Bridgeport, CT 06604. *

Yes

No

Please confirm which group you are available to participate in? *

If you are available for both please select both options.

Monday/Wednesday from 3:30 to 6:00 pm

Tuesday/Thursday from 3:30 to 6:00 pm