Passages at Cobscook Community Learning Center

Passages Application

About You
Your Name:
Email Address:
Phone:
Best Time to call:
Birthdate:
Your Current Address
Street:
City:
State:
Zip:
Directions to your Home
Your Permanent Address
Street:
City:
State:
Zip:

Other Contact Information
If you move, who is most likely to know how to reach you?
What is that person's phone number?

Your Parents
Your Parents' Names:
Parent's Phone:
Is it okay to call your parents? Yes No

Children's Information
Are you pregnant? Yes No
If so, what is your due date?
Childrens name(s) and birthdate(s)
Are you currently in a relationship with the birth father? Yes No
What is his name?
Where does he live?

School
Name of school you last attended:
What credits did you earn?
Who is a contact at the school?

Work
Are currently employed? Yes No
If yes, where?

Some Questions We Would Like to Ask
How did you hear about Passages?
Why are you interested in the passages Program now?
If you are working or involved with any other community agencies (TANF/ASPIRE, TEEN PARENT, EARLY START, WIC, MEDICAID, ETC), please list them here:
What is the one thing you've always wanted to do and are determined to do in your lifetime?
When are good days/times for the director to schedule a home visit?

As a non-profit community organization, the work of fulfilling the mission and vision of CCLC depends on thoughtful contributions of individuals, businesses and foundations. Please consider making a donation to support the ongoing efforts of the Learning Center. Contributions may be given online by Clicking Here or may be mailed to 10 Commissary Point Road; Lubec, ME 04652. Thank You.

© Copyright 2000-2008 the Cobscook Community Learning Center
10 Commissary Point Road, Trescott TWP, ME 04652 (207) 733-2233
Site design by Kevin Thompson 2003
Site related questions or comments? Email Me webmaster@thecclc.org

Your Current Address

Your Permanent Address