Urban Fellows Acceptance

Name *
Best number to reach you at *
Best number to reach you at
Parent Name *
Parent Name
Parent Phone Number *
Parent Phone Number
Do you accept your spot in Groundwork Bridgeport's Urban Fellows Program? *
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. *
Please confirm which group you are available to participate in? *
If you are available for both please select both options.