1. Supporting Safer Communities Intake Form*
Affirming Youth FoundationAmplify Community Resources, Inc.An Umbrella of Hope Re-Entry CoalitionBAMN Robotics CorporationBe Strong International, IncBelfonte Tacolcy CenterBeyond the BarsBlack Men BuildBrownsville Civic Neighborhood CenterCenter for Equitable Access and Treatment of TraumaChildren Of Inmates, Inc.Children’s Bereavement CenterCoalition of Florida Farmworkers Org, Inc

2. Program Start Date*

3. Age*

4. Which of the following best describes your race?*
American Indian or Alaskan NativeAsian or Asian AmericanBlack or African AmericanNative Hawaiian or other Pacific Islander

5. Which of the following best describes your ethnicity? *
American Indian or Alaskan NativeAsian or Asian AmericanBlack or African AmericanNative Hawaiian or other Pacific Islander

6. Which of the following best describes your gender identify?*
FemaleMaleNon-binary/Non-conformingPrefer not to say

7. Address*

8. Apt/Unit*

9. City*

10. State*

11. Zip Code*