Urban Fellows Acceptance

Name *

Name

First Name

Last Name

Your Email Address *

Best number to reach you at *

Best number to reach you at

(###)

###

####

Parent Name *

Parent Name

First Name

Last Name

Parent Email Address *

Parent Phone Number *

Parent Phone Number

(###)

###

####

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

Yes

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

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