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URL:
https://docs.google.com/forms/d/e/1FAIpQLSeu0oTVrHVJEaFB2B3WYb0i0rpGJlEQcPdOZbzmW0V86c7KeQ/viewform
Submission: On September 11 via manual from SG — Scanned from SG
Submission: On September 11 via manual from SG — Scanned from SG
Form analysis 1 forms found in the DOM
POST https://docs.google.com/forms/d/e/1FAIpQLSeu0oTVrHVJEaFB2B3WYb0i0rpGJlEQcPdOZbzmW0V86c7KeQ/formResponse
<form action="https://docs.google.com/forms/d/e/1FAIpQLSeu0oTVrHVJEaFB2B3WYb0i0rpGJlEQcPdOZbzmW0V86c7KeQ/formResponse" target="_self" method="POST" id="mG61Hd" jsmodel="TOfxwf Q91hve CEkLOc" data-shuffle-seed="7999168025285014379"
data-clean-viewform-url="https://docs.google.com/forms/d/e/1FAIpQLSeu0oTVrHVJEaFB2B3WYb0i0rpGJlEQcPdOZbzmW0V86c7KeQ/viewform" data-response="%.@.]" data-dlp-data="%.@.null,false]" data-first-entry="0" data-last-entry="13" data-is-first-page="true">
<div jscontroller="yUS4Lc" jsaction="rcuQ6b:rcuQ6b;UxRBlf:rcuQ6b;">
<div jsname="o6bZLc"><input type="hidden" name="entry.750131008" value=""><input type="hidden" name="entry.1665056596" value=""><input type="hidden" name="entry.1636483342" value=""><input type="hidden" name="entry.1494787284" value=""><input
type="hidden" name="entry.1986974289" value=""><input type="hidden" name="entry.901808483_year" value=""><input type="hidden" name="entry.901808483_month" value=""><input type="hidden" name="entry.901808483_day" value=""></div>
</div>
<div class="RH5hzf RLS9Fe">
<div class="lrKTG">
<div class="Dq4amc">
<div class="m7w29c O8VmIc tIvQIf"><noscript>
<div class="HB1eCd-X3SwIb-haAclf">
<div class="HB1eCd-X3SwIb-i8xkGf">
<div class="tk3N6e-cXJiPb tk3N6e-cXJiPb-TSZdd tk3N6e-cXJiPb-GMvhG">JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.</div>
</div><br>
</div>
</noscript>
<div class="JH79cc RVEQke b33AEc"></div>
<div class="N0gd6">
<div class="ahS2Le">
<div class="F9yp7e ikZYwf LgNcQe" dir="auto" role="heading" aria-level="1">WIOA Program Interest Form</div>
</div>
<div class="cBGGJ OIC90c" dir="auto">WIOA Program Intake Form<div><br></div>
<div>For information please contact Delano Pellom at delano.pellom@blackculturalzone.org or 510-214-2225</div>
</div>
<div jsname="F0H8Yc" class="liS6Hc"></div>
</div>
<div class="zAVwcb"></div>
<div class="DqBBlb">
<div class="Oh1Vtf">
<div class="kesdnc" id="SMMuxb">
<a jscontroller="A2m8uc" jsaction="rcuQ6b:npT2md; click:mAWTmb;" href="https://accounts.google.com/Login?continue=https%3A%2F%2Fdocs.google.com%2Fforms%2Fd%2Fe%2F1FAIpQLSeu0oTVrHVJEaFB2B3WYb0i0rpGJlEQcPdOZbzmW0V86c7KeQ%2Fviewform%3Ffbzx%3D7999168025285014379" aria-describedby="SMMuxb">Sign in to Google</a>
to save your progress. <a class="TYUeKb" jscontroller="rmdjlf" jsaction="rcuQ6b:npT2md; click:xdDXgc;" role="button" tabindex="0">Learn more</a></div>
</div>
<div class="zAVwcb"></div>
<div class="md0UAd" aria-hidden="true" dir="auto">* Indicates required question</div>
</div>
</div>
</div>
<div class="o3Dpx" role="list">
<div role="listitem">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n AgroKb oQYVNd">
<div jscontroller="v4y9Mc" jsaction="rcuQ6b:vZc4S;sPvj8e:d3sQLd;O22p3e:zjh6rb;AHmuwe:h06R8;b2trFe:eVidQc;">
<div class="z12JJ">
<div class="HoXoMd D1wxyf RjsPE" dir="auto" role="heading" aria-level="3"><span class="M7eMe">Email</span><span class="vnumgf" id="i4" aria-label="Required question"> *</span></div>
</div>
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="email" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="email" tabindex="0" aria-label="Your email address" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Your email address</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i3" role="alert"></div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[1910512736,"First and Last Name ",null,0,[[750131008,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"First and Last Name "]],"i5","i6","i7",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i5" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i8"><span class="M7eMe">First and Last Name </span><span class="vnumgf" id="i8" aria-label="Required question"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i6"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i5" aria-describedby="i6 i7" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Your answer</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i7" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[952788331,"Address ",null,1,[[1665056596,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Address "]],"i9","i10","i11",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i9" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i12"><span class="M7eMe">Address </span><span class="vnumgf" id="i12" aria-label="Required question"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i10"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="edhGSc zKHdkd kRy7qc RdH0ib yqQS1" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="RpC4Ne oJeWuf">
<div class="F1pOBe snByac" aria-hidden="true" jsname="LwH6nd">Your answer</div>
<div class="Pc9Gce Wic03c"><textarea class="KHxj8b tL9Q4c" jsname="YPqjbf" data-rows="1" tabindex="0" aria-label="Your answer" jscontroller="gZjhIf" jsaction="input:Lg5SV;ti6hGc:XMgOHc;rcuQ6b:WYd;" required="" dir="auto"
data-initial-dir="auto" data-initial-value="" aria-labelledby="i9" aria-describedby="i10 i11" style="height: 24px;" aria-disabled="false"></textarea></div>
<div class="z0oSpf mIZh1c"></div>
<div jsname="XmnwAc" class="Bfurwb cXrdqd"></div>
</div>
<div class="jE8NUc">
<div jsname="ty6ygf" class="YElZX Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i11" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[444954213,"Phone number - (By providing your mobile number, you agree to receive SMS messages from Black Cultural Zone CDC. Message and data rates may apply. Reply STOP to opt-out when you received a text message. You acknowledge that your information will be used in accordance with our privacy policy.)",null,0,[[1636483342,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Phone number - (\u003cspan style\u003d\"white-space:pre-wrap\"\u003eBy providing your mobile number, you agree to receive SMS messages from Black Cultural Zone CDC. Message and data rates may apply. Reply STOP to opt-out when you received a text message. You acknowledge that your information will be used in accordance with our privacy policy.)\u003c/span\u003e"]],"i13","i14","i15",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i13" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i16"><span class="M7eMe">Phone number - (<span style="white-space:pre-wrap">By providing your mobile number, you agree to receive SMS messages
from Black Cultural Zone CDC. Message and data rates may apply. Reply STOP to opt-out when you received a text message. You acknowledge that your information will be used in accordance with our privacy
policy.)</span></span><span class="vnumgf" id="i16" aria-label="Required question"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i14"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i13" aria-describedby="i14 i15" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Your answer</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i15" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[953087913,"Email",null,0,[[1494787284,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Email"]],"i17","i18","i19",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i17" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i20"><span class="M7eMe">Email</span><span class="vnumgf" id="i20" aria-label="Required question"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i18"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i17" aria-describedby="i18 i19" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Your answer</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i19" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[245376625,"Age",null,0,[[1986974289,null,true,null,null,null,null,null,null,null,[]]],null,null,null,null,null,null,[null,"Age"]],"i21","i22","i23",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i21" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3" aria-describedby="i24"><span class="M7eMe">Age</span><span class="vnumgf" id="i24" aria-label="Required question"> *</span></div>
<div class="gubaDc OIC90c RjsPE" id="i22"></div>
</div>
</div>
<div jscontroller="oCiKKc" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:d3sQLd;AHmuwe:h06R8;" class="AgroKb">
<div class="rFrNMe k3kHxc RdH0ib yqQS1 zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="YPqjbf">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="text" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i21" aria-describedby="i22 i23" aria-disabled="false" required="" dir="auto" data-initial-dir="auto"
data-initial-value="">
<div jsname="LwH6nd" class="ndJi5d snByac" aria-hidden="true">Your answer</div>
</div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i23" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[308938008,"Date of Birth",null,9,[[901808483,null,false,null,null,null,null,[false,true],null,null,[]]],null,null,null,null,null,null,[null,"Date of Birth"]],"i25","i26","i27",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i25" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">Date of Birth</span></div>
<div class="gubaDc OIC90c RjsPE" id="i26"></div>
</div>
</div>
<div jscontroller="lLliLe" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;wkbFue:d3sQLd;sPvj8e:d3sQLd;JIbuQc:d3sQLd; keyup:d3sQLd;" data-includesyear="true" data-supportsdate="true">
<div class="A6uyJd">
<div class="o7cIKf" jsname="q7Lpsb" aria-labelledby="i25" aria-describedby="i26 i27">
<div id="i29" class="ds3H7c">Date</div>
<div class="rFrNMe yqQS1 hatWr zKHdkd" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="jPalo">
<div class="aCsJod oJeWuf">
<div class="aXBtI Wic03c">
<div class="Xb9hP"><input type="date" class="whsOnd zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-labelledby="i29" aria-disabled="false" max="2074-01-01" data-initial-value=""></div>
<div class="i9lrp mIZh1c"></div>
<div jsname="XmnwAc" class="OabDMe cXrdqd"></div>
</div>
</div>
<div class="LXRPh">
<div jsname="ty6ygf" class="ovnfwe Is7Fhb"></div>
</div>
</div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i27" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[1766588133,"Do you reside in any of these areas?",null,2,[[1594883323,[["East Oakland",null,null,null,false],["West Oakland",null,null,null,false],["Central/Fruitvale",null,null,null,false],["",null,null,null,true]],false,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Do you reside in any of these areas?"]],"i30","i31","i32",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i30" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">Do you reside in any of these areas?</span></div>
<div class="gubaDc OIC90c RjsPE" id="i31"></div>
</div>
</div>
<div jscontroller="UmOCme" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;JIbuQc:RgMCxe(YlCLKb);sPvj8e:d3sQLd;TYy3Ne:RgMCxe;" class="oyXaNc" jsname="GCYh9b"><input type="hidden" name="entry.1594883323_sentinel" jsname="DTMEae">
<div jscontroller="eFy6Rc" jsaction="sPvj8e:Gh295d" jsname="cnAzRb">
<div class="lLfZXe fnxRtf cNDBpf" jscontroller="wPRNsd" jsshadow="" jsaction="keydown:I481le;JIbuQc:JIbuQc;rcuQ6b:rcuQ6b" jsname="wCJL8" aria-labelledby="i30" aria-describedby="i31 i32" role="radiogroup"><span jsslot=""
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<div class="SG0AAe">
<div class="nWQGrd zwllIb"><label for="i34" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i34" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="East Oakland" data-value="East Oakland" role="radio" aria-checked="false" aria-posinset="1" aria-setsize="4" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">East Oakland</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i37" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i37" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="West Oakland" data-value="West Oakland" role="radio" aria-checked="false" aria-posinset="2" aria-setsize="4" tabindex="-1">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">West Oakland</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i40" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i40" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="Central/Fruitvale" data-value="Central/Fruitvale" role="radio" aria-checked="false" aria-posinset="3" aria-setsize="4" tabindex="-1">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">Central/Fruitvale</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb zfdaxb" jsname="MaDKvc"><label for="i43" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i43" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" data-value="__other_option__" role="radio" aria-checked="false" aria-posinset="4" aria-setsize="4" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc">Other:</span></div>
</div>
</div>
</label>
<div class="pIDwKe" jsaction="keydown:npT2md" jsshadow=""><span jsslot="">
<div class="RWzxl yqQS1 SjlgO" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="R6ztRd">
<div class="KzNPgc oJeWuf">
<div class="JGptt"><input type="text" class="Hvn9fb zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-label="Other response" dir="auto" data-initial-dir="auto" data-initial-value="" aria-disabled="false">
</div>
<div class="SPcBRc mIZh1c"></div>
<div jsname="XmnwAc" class="kPBwDb cXrdqd"></div>
</div>
</div>
</span></div>
</div>
</div>
</span></div>
</div>
<div class="Jwjdfe">
<div class="dMALK bQXwDc" jsname="YlCLKb">
<div role="button" class="uArJ5e UQuaGc kCyAyd" jscontroller="VXdfxd"
jsaction="click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;"
jsshadow="" tabindex="0">
<div class="Fvio9d MbhUzd" jsname="ksKsZd"></div>
<div class="e19J0b CeoRYc"></div><span jsslot="" class="l4V7wb Fxmcue"><span class="NPEfkd RveJvd snByac">Clear selection</span></span>
</div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i32" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[1697011508,"Are you currently or formerly involved in the legal system?",null,2,[[963991811,[["Yes",null,null,null,false],["No",null,null,null,false]],false,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Are you currently or formerly involved in the legal system?\u003cbr\u003e"]],"i46","i47","i48",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i46" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">Are you currently or formerly involved in the legal system?<br></span></div>
<div class="gubaDc OIC90c RjsPE" id="i47"></div>
</div>
</div>
<div jscontroller="UmOCme" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;JIbuQc:RgMCxe(YlCLKb);sPvj8e:d3sQLd;TYy3Ne:RgMCxe;" class="oyXaNc" jsname="GCYh9b"><input type="hidden" name="entry.963991811_sentinel" jsname="DTMEae">
<div jscontroller="eFy6Rc" jsaction="sPvj8e:Gh295d" jsname="cnAzRb">
<div class="lLfZXe fnxRtf cNDBpf" jscontroller="wPRNsd" jsshadow="" jsaction="keydown:I481le;JIbuQc:JIbuQc;rcuQ6b:rcuQ6b" jsname="wCJL8" aria-labelledby="i46" aria-describedby="i47 i48" role="radiogroup"><span jsslot=""
role="presentation" jsname="bN97Pc" class="H2Gmcc tyNBNd">
<div class="SG0AAe">
<div class="nWQGrd zwllIb"><label for="i50" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i50" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="Yes" data-value="Yes" role="radio" aria-checked="false" aria-posinset="1" aria-setsize="2" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">Yes</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i53" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i53" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="No" data-value="No" role="radio" aria-checked="false" aria-posinset="2" aria-setsize="2" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">No</span></div>
</div>
</div>
</label></div>
</div>
</span></div>
</div>
<div class="Jwjdfe">
<div class="dMALK bQXwDc" jsname="YlCLKb">
<div role="button" class="uArJ5e UQuaGc kCyAyd" jscontroller="VXdfxd"
jsaction="click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;"
jsshadow="" tabindex="0">
<div class="Fvio9d MbhUzd" jsname="ksKsZd"></div>
<div class="e19J0b CeoRYc"></div><span jsslot="" class="l4V7wb Fxmcue"><span class="NPEfkd RveJvd snByac">Clear selection</span></span>
</div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i48" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[952849258,"Are you currently in enrolled in school? ",null,4,[[1797710550,[["Yes",null,null,null,false],["No",null,null,null,false]],false,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Are you currently in enrolled in school? "]],"i56","i57","i58",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i56" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">Are you currently in enrolled in school? </span></div>
<div class="gubaDc OIC90c RjsPE" id="i57"></div>
</div>
</div>
<div jscontroller="sW52Ae" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:sEDvJ;JIbuQc:d3sQLd(MPu53c);" class="Y6Myld"><input type="hidden" name="entry.1797710550_sentinel" jsname="DTMEae">
<div role="list" aria-labelledby="i56" aria-describedby="i57 i58 i60" class="">
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i61" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i61" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Yes" data-answer-value="Yes" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">Yes</span></div>
</div>
</div>
</label></div>
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i64" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i64" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="No" data-answer-value="No" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">No</span></div>
</div>
</div>
</label></div>
</div>
<div id="i60" class="fKfAyc"></div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i58" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[189400203,"Are you a parent to a child(ren) who are under 18 years old?",null,2,[[764615555,[["Yes",null,null,null,false],["No",null,null,null,false]],false,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Are you a parent to a child(ren) who are under 18 years old?"]],"i67","i68","i69",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i67" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">Are you a parent to a child(ren) who are under 18 years old?</span></div>
<div class="gubaDc OIC90c RjsPE" id="i68"></div>
</div>
</div>
<div jscontroller="UmOCme" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;JIbuQc:RgMCxe(YlCLKb);sPvj8e:d3sQLd;TYy3Ne:RgMCxe;" class="oyXaNc" jsname="GCYh9b"><input type="hidden" name="entry.764615555_sentinel" jsname="DTMEae">
<div jscontroller="eFy6Rc" jsaction="sPvj8e:Gh295d" jsname="cnAzRb">
<div class="lLfZXe fnxRtf cNDBpf" jscontroller="wPRNsd" jsshadow="" jsaction="keydown:I481le;JIbuQc:JIbuQc;rcuQ6b:rcuQ6b" jsname="wCJL8" aria-labelledby="i67" aria-describedby="i68 i69" role="radiogroup"><span jsslot=""
role="presentation" jsname="bN97Pc" class="H2Gmcc tyNBNd">
<div class="SG0AAe">
<div class="nWQGrd zwllIb"><label for="i71" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i71" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="Yes" data-value="Yes" role="radio" aria-checked="false" aria-posinset="1" aria-setsize="2" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">Yes</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i74" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i74" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="No" data-value="No" role="radio" aria-checked="false" aria-posinset="2" aria-setsize="2" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">No</span></div>
</div>
</div>
</label></div>
</div>
</span></div>
</div>
<div class="Jwjdfe">
<div class="dMALK bQXwDc" jsname="YlCLKb">
<div role="button" class="uArJ5e UQuaGc kCyAyd" jscontroller="VXdfxd"
jsaction="click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;"
jsshadow="" tabindex="0">
<div class="Fvio9d MbhUzd" jsname="ksKsZd"></div>
<div class="e19J0b CeoRYc"></div><span jsslot="" class="l4V7wb Fxmcue"><span class="NPEfkd RveJvd snByac">Clear selection</span></span>
</div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i69" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[496816481,"What is your ethnicity? (check all that apply)",null,4,[[743434856,[["African American/Black",null,null,null,false],["Latinx",null,null,null,false],["Native American",null,null,null,false],["Asian/Pacific Islander",null,null,null,false],["",null,null,null,true]],false,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"What is your ethnicity? (check all that apply)\u003cbr\u003e"]],"i77","i78","i79",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i77" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">What is your ethnicity? (check all that apply)<br></span></div>
<div class="gubaDc OIC90c RjsPE" id="i78"></div>
</div>
</div>
<div jscontroller="sW52Ae" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:sEDvJ;JIbuQc:d3sQLd(MPu53c);" class="Y6Myld"><input type="hidden" name="entry.743434856_sentinel" jsname="DTMEae">
<div role="list" aria-labelledby="i77" aria-describedby="i78 i79 i81" class="">
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i82" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i82" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="African American/Black" data-answer-value="African American/Black" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">African American/Black</span></div>
</div>
</div>
</label></div>
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i85" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i85" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Latinx" data-answer-value="Latinx" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">Latinx</span></div>
</div>
</div>
</label></div>
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i88" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i88" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Native American" data-answer-value="Native American" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">Native American</span></div>
</div>
</div>
</label></div>
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i91" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i91" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Asian/Pacific Islander" data-answer-value="Asian/Pacific Islander" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">Asian/Pacific Islander</span></div>
</div>
</div>
</label></div>
<div class="eBFwI RVLOe" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c">
<div class="pzmVo"><label for="i94" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i94" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Other:" data-answer-value="__other_option__" data-other-checkbox="true" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf">Other:</span></div>
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</div>
</label>
<div class="xVfcde">
<div class="RWzxl yqQS1 IpuEke" jscontroller="pxq3x" jsaction="clickonly:KjsqPd; focus:Jt1EX; blur:fpfTEe; input:Lg5SV" jsshadow="" jsname="R6ztRd">
<div class="KzNPgc oJeWuf">
<div class="JGptt"><input type="text" class="Hvn9fb zHQkBf" jsname="YPqjbf" autocomplete="off" tabindex="0" aria-label="Other response" dir="auto" data-initial-dir="auto" data-initial-value="" aria-disabled="false"></div>
<div class="SPcBRc mIZh1c"></div>
<div jsname="XmnwAc" class="kPBwDb cXrdqd"></div>
</div>
</div>
</div>
</div>
</div>
</div>
<div id="i81" class="fKfAyc"></div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i79" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[1181435330,"Please select your family annual (yearly) income range:",null,2,[[2004177723,[["$0 - $20,000",null,null,null,false],["$20,000 - $40,000",null,null,null,false],["$40,000 - $60,000",null,null,null,false],["$60,000 - $80,000",null,null,null,false],["$80,000 +",null,null,null,false]],false,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"Please select your family annual (yearly) income range:"]],"i97","i98","i99",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i97" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">Please select your family annual (yearly) income range:</span></div>
<div class="gubaDc OIC90c RjsPE" id="i98"></div>
</div>
</div>
<div jscontroller="UmOCme" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;JIbuQc:RgMCxe(YlCLKb);sPvj8e:d3sQLd;TYy3Ne:RgMCxe;" class="oyXaNc" jsname="GCYh9b"><input type="hidden" name="entry.2004177723_sentinel" jsname="DTMEae">
<div jscontroller="eFy6Rc" jsaction="sPvj8e:Gh295d" jsname="cnAzRb">
<div class="lLfZXe fnxRtf cNDBpf" jscontroller="wPRNsd" jsshadow="" jsaction="keydown:I481le;JIbuQc:JIbuQc;rcuQ6b:rcuQ6b" jsname="wCJL8" aria-labelledby="i97" aria-describedby="i98 i99" role="radiogroup"><span jsslot=""
role="presentation" jsname="bN97Pc" class="H2Gmcc tyNBNd">
<div class="SG0AAe">
<div class="nWQGrd zwllIb"><label for="i101" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i101" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="$0 - $20,000" data-value="$0 - $20,000" role="radio" aria-checked="false" aria-posinset="1" aria-setsize="5" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">$0 - $20,000</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i104" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i104" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="$20,000 - $40,000" data-value="$20,000 - $40,000" role="radio" aria-checked="false" aria-posinset="2" aria-setsize="5" tabindex="-1">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">$20,000 - $40,000</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i107" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i107" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="$40,000 - $60,000" data-value="$40,000 - $60,000" role="radio" aria-checked="false" aria-posinset="3" aria-setsize="5" tabindex="-1">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">$40,000 - $60,000</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i110" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i110" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="$60,000 - $80,000" data-value="$60,000 - $80,000" role="radio" aria-checked="false" aria-posinset="4" aria-setsize="5" tabindex="-1">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">$60,000 - $80,000</span></div>
</div>
</div>
</label></div>
<div class="nWQGrd zwllIb"><label for="i113" class="docssharedWizToggleLabeledContainer ajBQVb">
<div class="bzfPab wFGF8">
<div class="d7L4fc bJNwt FXLARc aomaEc ECvBRb">
<div id="i113" class="Od2TWd hYsg7c" jscontroller="D8e5bc"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" aria-label="$80,000 +" data-value="$80,000 +" role="radio" aria-checked="false" aria-posinset="5" aria-setsize="5" tabindex="0">
<div class="x0k1lc MbhUzd"></div>
<div class="uyywbd"></div>
<div class="vd3tt">
<div class="AB7Lab Id5V1">
<div class="rseUEf nQOrEb"></div>
</div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac OvPDhc OIC90c">$80,000 +</span></div>
</div>
</div>
</label></div>
</div>
</span></div>
</div>
<div class="Jwjdfe">
<div class="dMALK bQXwDc" jsname="YlCLKb">
<div role="button" class="uArJ5e UQuaGc kCyAyd" jscontroller="VXdfxd"
jsaction="click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;"
jsshadow="" tabindex="0">
<div class="Fvio9d MbhUzd" jsname="ksKsZd"></div>
<div class="e19J0b CeoRYc"></div><span jsslot="" class="l4V7wb Fxmcue"><span class="NPEfkd RveJvd snByac">Clear selection</span></span>
</div>
</div>
</div>
</div>
<div jsname="Rfh2Tc" class="SL4Sz" id="i99" role="alert"></div>
</div>
</div>
</div>
<div class="Qr7Oae" role="listitem">
<div jsmodel="CP1oW"
data-params="%.@.[657430659,"How can the program support you? (check all that apply)",null,4,[[320589569,[["Providing an orientation that informs individuals of the full array of services available",null,null,null,false],["Leadership development",null,null,null,false],["Supportive services (mental health counseling, accessing public benefits, health care, cash aid, etc)",null,null,null,false],["Mentoring, tutoring, study skills training, instruction, and evidence-based dropout recovery strategies",null,null,null,false],["Improving educational skills and competency",null,null,null,false],["Financial literacy: Banking Basics, Budgeting, Employment and Taxes, Managing Credit and Debt",null,null,null,false],["Entrepreneurial skills, business development support",null,null,null,false],["Job/employment information and career counseling",null,null,null,false],["Community service",null,null,null,false],["Alternative secondary school services, or dropout recovery service",null,null,null,false],["Paid and unpaid work experiences",null,null,null,false],["Occupational skill training",null,null,null,false],["Training for a specific occupation or occupational cluster",null,null,null,false]],false,null,null,null,null,null,false,null,[]]],null,null,null,null,null,null,[null,"How can the program support you? (check all that apply)"]],"i116","i117","i118",false]">
<div jscontroller="sWGJ4b" jsaction="EEvAHc:yfX9oc;" jsname="WsjYwc" class="geS5n">
<div class="z12JJ">
<div class="M4DNQ">
<div id="i116" class="HoXoMd D1wxyf RjsPE" role="heading" aria-level="3"><span class="M7eMe">How can the program support you? (check all that apply)</span></div>
<div class="gubaDc OIC90c RjsPE" id="i117"></div>
</div>
</div>
<div jscontroller="sW52Ae" jsaction="rcuQ6b:vZc4S;O22p3e:zjh6rb;b2trFe:eVidQc;sPvj8e:sEDvJ;JIbuQc:d3sQLd(MPu53c);" class="Y6Myld"><input type="hidden" name="entry.320589569_sentinel" jsname="DTMEae">
<div role="list" aria-labelledby="i116" aria-describedby="i117 i118 i120" class="">
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i121" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i121" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Providing an orientation that informs individuals of the full array of services available"
data-answer-value="Providing an orientation that informs individuals of the full array of services available" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">Providing an orientation that informs individuals of the full array of services available</span></div>
</div>
</div>
</label></div>
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i124" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i124" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Leadership development" data-answer-value="Leadership development" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">Leadership development</span></div>
</div>
</div>
</label></div>
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i127" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i127" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Supportive services (mental health counseling, accessing public benefits, health care, cash aid, etc)"
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<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
</div>
</div>
<div class="YEVVod">
<div class="ulDsOb"><span dir="auto" class="aDTYNe snByac n5vBHf OIC90c">Supportive services (mental health counseling, accessing public benefits, health care, cash aid, etc)</span></div>
</div>
</div>
</label></div>
<div class="eBFwI" role="listitem" jsaction="JIbuQc:aj0Jcf" jscontroller="lWjoT" jsname="MPu53c"><label for="i130" class="docssharedWizToggleLabeledContainer Yri8Nb">
<div class="bzfPab wFGF8">
<div id="i130" class="uVccjd aiSeRd FXLARc wGQFbe BJHAP oLlshd" jscontroller="EcW08c"
jsaction="keydown:I481le;dyRcpb:dyRcpb;click:cOuCgd; mousedown:UX7yZ; mouseup:lbsD7e; mouseenter:tfO1Yc; mouseleave:JywGue; focus:AHmuwe; blur:O22p3e; contextmenu:mg9Pef;touchstart:p6p2H; touchmove:FwuNnf; touchend:yfqBxc(preventDefault=true); touchcancel:JMtRjd;"
jsshadow="" jsname="FkQz1b" aria-label="Mentoring, tutoring, study skills training, instruction, and evidence-based dropout recovery strategies"
data-answer-value="Mentoring, tutoring, study skills training, instruction, and evidence-based dropout recovery strategies" role="checkbox" aria-checked="false" tabindex="0">
<div class="PkgjBf MbhUzd"></div>
<div class="uHMk6b fsHoPb"></div>
<div class="rq8Mwb">
<div class="TCA6qd">
<div class="MbUTNc oyD5Oc"></div>
<div class="Ii6cVc oyD5Oc"></div>
</div>
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JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload. WIOA Program Interest Form WIOA Program Intake Form For information please contact Delano Pellom at delano.pellom@blackculturalzone.org or 510-214-2225 Sign in to Google to save your progress. Learn more * Indicates required question Email * Your email address First and Last Name * Your answer Address * Your answer Phone number - (By providing your mobile number, you agree to receive SMS messages from Black Cultural Zone CDC. Message and data rates may apply. Reply STOP to opt-out when you received a text message. You acknowledge that your information will be used in accordance with our privacy policy.) * Your answer Email * Your answer Age * Your answer Date of Birth Date Do you reside in any of these areas? East Oakland West Oakland Central/Fruitvale Other: Clear selection Are you currently or formerly involved in the legal system? Yes No Clear selection Are you currently in enrolled in school? Yes No Are you a parent to a child(ren) who are under 18 years old? Yes No Clear selection What is your ethnicity? (check all that apply) African American/Black Latinx Native American Asian/Pacific Islander Other: Please select your family annual (yearly) income range: $0 - $20,000 $20,000 - $40,000 $40,000 - $60,000 $60,000 - $80,000 $80,000 + Clear selection How can the program support you? (check all that apply) Providing an orientation that informs individuals of the full array of services available Leadership development Supportive services (mental health counseling, accessing public benefits, health care, cash aid, etc) Mentoring, tutoring, study skills training, instruction, and evidence-based dropout recovery strategies Improving educational skills and competency Financial literacy: Banking Basics, Budgeting, Employment and Taxes, Managing Credit and Debt Entrepreneurial skills, business development support Job/employment information and career counseling Community service Alternative secondary school services, or dropout recovery service Paid and unpaid work experiences Occupational skill training Training for a specific occupation or occupational cluster Submit Clear form Never submit passwords through Google Forms. This form was created inside Black Cultural Zone Community Development Corporation/East Oakland Black Cultural Zone Collaborative. Report Abuse Forms