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E3 Power Centers Referral Form





* - required fields   

Youth's Personal Information

Next Court Date:
*First Name:
*Last Name:
*Age:
*Gender:  Male     Female
*Home Address:
Suite/Apt/Floor:
*City:
*State:
*Zip:
*Phone:  Ex: 123-456-7890

Program Information

*Youth is interested in attending/transferring to the following Center/program: E3 Center City
E3 North (formally E3 Girard)
E3 West
E3 Southwest
YESPhilly
Youth is interested in (check all that apply): GED Preparation
Job Readiness Training
Community Service
General Reading/Math Skills-Building
Work Exposure (Internship)
Life Skills Programming
Other:

Documentation

Youth possesses (check all documents that youth currently has in his/her possession): Driver's License or State ID
Social Security Card
Birth Certificate

Notes

(e.g. youth has court date coming up quickly, youth only needs Math section of GED, etc.)
You have characters left. (Maximum characters: 500)

Submitter's Information

*Full Name of Submitter:
*Submitter's Title:
*Submitter's Agency/Office:
*Submitter's Email:
*Submitter's Phone:  Ex: 123-456-7890
Submitter's Fax:  Ex: 123-456-7890

For Center Staff Use Only

This form was completed by the following E3 Center/program on behalf of youth: E3 Center City
E3 North (formerly E3 Girard)
E3 West
E3 Southwest
YESPhilly
Referral – court-involved
Referral – NOT court-involved
Transfer – current student
    

 

E3 Center City Branch
112 N. Broad Street
12th Floor
Philadelphia, PA 19102

Director: Tara Mullen

phone: 267-238-3180

For youth intake ask for Tara or email: tara.mullen@jevs.org
E3 North Branch
2800 N. American Street
Philadelphia, PA 19133

Director: Brendan Conlin

phone: 215-763-8870 x7224
fax: 215-291-0408

For youth intake ask for Elizabeth or email: padillael@congreso.net
E3 Southwest Branch
CISP Education Center
5407-09 Grays Avenue
Philadelphia, PA 19143

Director: Nyne Sellers

phone: 267-299-2513
fax: 215-724-1201

For youth intake ask for Collette or email: cbutler@cisphl.org

E3 West Branch
4111 Lancaster Avenue
Philadelphia, PA 19104

Director: Selena Tucker

phone: 215-387-2137
fax: 215-387-2139

For youth intake ask for Erinn or email: erin@phmc.org
YESPhilly
1231 North Broad Street
2nd Floor
Philadelphia, PA 19122

Director: Gary Paprocki

phone: 215-769-0340 x233
fax: 215-769-0344

For youth intake ask for Deborah or email: dharris@yesphilly.org

 

 


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