Name: *

First Name

Last Name

Phone: *

(###)

###

####

Preferred Contact Method: *

Phone

Email

Text

Current Address: *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Are you applying for yourself or on behalf of someone else? *

Myself

My child

Someone else

Which of our programs are you interested in? (Select all that apply) *

Career Mentorship

Trauma-Informed Therapy or Counseling

Community Events or Workshops

Access to Educational Resources (e.g., school supplies, books, tech)

Other

Are you currently receiving support from any other organizations or services?

Yes

No

Do you currently attend school or college? *

Yes

No

Are you the first in your family to attend college or pursue higher education?

Yes

No

Have you experienced any of the following challenges in the past 2 years? (Select all that apply) *

Housing insecurity or homelessness

Loss of a parent/guardian or caregiver

Foster care involvement

Community violence or trauma

Mental health struggles

Academic difficulties

Financial hardship

Other:

Are you under the age of 18? *

Yes

No

Do you consent to NorthStar contacting you to follow up and match you with services? *

Yes

No