Interest Form for Chatham County | Capital Area NextGen

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Interest Form - Chatham County

Referral Source

First and Last Name

Is the individual between the ages of 16-24?

Email

Phone

If you are referring yourself or are a parent referring your child, did a community organization tell you about NextGen?

Name of your agency

Salvation Army
126 Village Lake Road
Siler City, NC 27344
(336) 763-6400

What organization?

Email for agency point of contact

Phone for point of contact

Check all that apply to the individual

Pregnant or Parenting

Did not complete high school / drop-out

Homeless

In or aged out of foster care

Justice-involved

Has a disability

Current or previous IEP

Substance Use / Recovery / At-risk

SNAP/TANF or state assistance

What services does the individual need?

HS Diploma/GED

Job Training/Apprenticeship

Employment

Supportive Services

Undetermined

Thank you. Your submission was successful!

Contact a Center

Equal Opportunity Employer/Program

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