First Name *
Last Name *
Birthdate *
Phone *
Email *
County of Residence *
Adams
Allen
Bartholomew
Benton
Blackford
Boone
Brown
Carroll
Cass
Clark
Clay
Clinton
Crawford
Daviess
Dearborn
Decatur
DeKalb
Delaware
Dubois
Elkhart
Fayette
Floyd
Fountain
Franklin
Fulton
Gibson
Grant
Greene
Hamilton
Hancock
Harrison
Hendricks
Henry
Howard
Huntington
Jackson
Jasper
Jay
Jefferson
Jennings
Johnson
Knox
Kosciusko
LaGrange
Lake
LaPorte
Lawrence
Madison
Marion
Marshall
Martin
Miami
Monroe
Montgomery
Morgan
Newton
Noble
Ohio
Orange
Other (outside Indiana)
Owen
Parke
Perry
Pike
Porter
Posey
Pulaski
Putnam
Randolph
Ripley
Rush
Scott
Shelby
Spencer
St. Joseph
Starke
Steuben
Sullivan
Switzerland
Tippecanoe
Tipton
Union
Vanderburgh
Vermillion
Vigo
Wabash
Warren
Warrick
Washington
Wayne
Wells
White
Whitley
Would you be willing to allow us to share your story? (identifying information can be removed, and we will contact you before doing so.) *
No
Yes
Ethnicity
Non-Hispanic
Hispanic
Race
American Indian or Alaskan Native
Asian
Black or African American
Middle Eastern
Native Hawaiian/Other Pacidic Islander
White or Caucasian
Multiracial
Other
Do you meet DCS eligibility requirements for IYAB participation? *
Eligible
Ineligible
Current DCS Involvement *
In DCS Care (Age 15-18)
IL Services (Age 16-18)
Collaborative Care (Age 18-21)
Voluntary Services (Age 18-23)
Previously but do not currently participate in DCS.
DCS Case Manager or 3CM Name
DCS Case Manager or 3CM Email
DCS Case Manager or 3CM Phone
IL Worker/Life Coach Name
IL Worker/Life Coach Email
IL Worker/Life Coach Phone
Current Probation Case? *
Yes
No
Juvenile Probation Officer Name
Juvenile Probation Officer Email
Juvenile Probation Officer Number
IYAB Areas of Interest *
Court Proceedings
Volunteering
Racial Justice, Equity, & Inclusion
Speakers Bureau
LGBTQ+ & Gender Identity
Mental Health and/or Substance Abuse
Permanancy
Youth Voice
Residential Services
Peer Mentoring
Juvenile Probation
Foster Parent Training
Education (High School/College)
Employment
Homelessness
IYAB Areas of Interest Additional
Comments
Submit Application