Living Safely in Jackson Square (LSJS) Organizer Application If you are having issues submitting this application, please email recruitment@hydesquare.org or call 617-524-8303.Why are you interested in being a Youth Community Organizer?*3-5 SentencesParticipant Information:Name:* First Last Date of Birth:* Month Day Year Age:* Gender:* Female Male Non-Binary Gender Questioning Gender Transitioning Other If other, please specify:* Which of the following best describes you? Please choose one answer:* Asian or Pacific Islander Black or African American Hispanic or Latino Native American or Alaskan Native White or Caucasian Multiracial or biracial A race/ethnicity not listed here If you selected "Multiracial or Biracial or race/ethnicity not listed here", please specify:* Country of Birth*BrazilCape VerdeColombiaCosta RicaCubaDominican RepublicEcuadorEl SalvadorGuatemalaHaitiHondurasJamaicaMexicoOtherPanamaPeruPuerto RicoUnited States of AmericaVenezuelaIf you selected "other" above, please write in the name of the country below.* Address:* Street Address City State AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific ZIP Code Home Phone Number:*Cell Phone Number (if available):*Email Address:* What are your preferred method (s) of communication? Email Text Phone Call Are you currently enrolled in school?* High School College Not currently in school What grade are you in?8th9th10th11th12th7th6th5th4th3rd2nd1stOtherHS GradWhat school do you currently attend?Academy of the Pacific RimAnother Course to CollegeBoston Adult Technical AcademyBoston Arts AcademyBoston CollegiateRuth Batson AcademyBoston Day & Evening AcademyBoston Green AcademyBoston International SchoolBoston Latin AcademyBoston Latin SchoolBoston PreparatoryBoston Teachers Union K-8 SchoolBoston Trinity AcademyBrighton HighBrooke 8th Grade AcademyBrooke HighBurke HighCity on a HillCity on a Hill (Dudley)Codman AcademyCommunity Academy of Science & HealthConservatory LabCristo Rey BostonCurley K-8Dearborn STEM AcademyEast Boston HighEdison K-8Edward M. Kennedy Academy for Health CareersEnglish HighExcel AcademyExcel HighFenway HighGreater Egleston High SchoolHenderson K-12 InclusionHennigan K-8Hernandez K-8Irving MiddleJoseph LeeKennedy Academy for Health Careers 11-12Kennedy Academy for Health Careers 9-10Madison ParkMarbleheadMargarita Muniz AcademyMATCH HighMATCH MiddleMelvin King South End AcademyMeridian AcademyMission Hill K-8Murphy K-8Newcomers AcademyNew Mission HighO'BryantQuincy Upper SchoolRoxbury PreparatorySharonSnowden InternationalTecca Online SchoolTechBoston AcademyTobin K-8UP Academy DorchesterYoung Achievers Science & Math K-8OtherMETCO OtherCharlestown HighIf you selected "other or METCO" above, please write in the name of your school below.* How did you find out about our program?*Artes Culturales: formerly Music Clubhouse (MCH)Current or Former Participant of HSTFFamily MemberFlyerFriendHSTF Community EventOpportunity FairSocial MediaSchool PresentationSchool Field Trip to HSTFTeacherOtherIf you selected "Other, Family Member, Friend, or Teacher" above please specify:* Parent / Guardian InformationIf you are under the age of 18 please make sure to have your parent/guardian fill out their information below. Parent / Guardian Name: First and Last Relationship to Youth: AddressStreet City, State, ZIP CodeHome Phone Number:Cell Phone Number:Email Address: Parent/Guardian Country of BirthBrazilCape VerdeColombiaCosta RicaCubaDominican RepublicEcuadorEl SalvadorGuatemalaHaitiHondurasJamaicaMexicoOtherPanamaPeruPuerto RicoUnited States of AmericaVenezuelaIf you selected "other" above, please write in the name of the country below. Consent*The information provided on this form is true and accurate to the best of my knowledge and I give permission for my child to participate in Hyde Square Task Force programs and activities. You have my consent.Parent / Guardian Signature: Participant Signature:* Date:* MM slash DD slash YYYY Δ
