Project Avary Enrollment ApplicationReferral Form

Program Website: Project Avary

Thank you for your interest in Project Avary, a community for youth with current or formerly incarcerated caregivers (prison, jail, or ICE detainment). To learn more about the program, please fill out the questions below. We will contact the caregiver within a few days of receiving the application.

*If you are not the youth's caregiver, and would like to refer a youth to our program, please let the family know that you submitted this referral before we contact them.

If you have any questions, please email our Program Manager, Ahtziri: ahtziri@projectavary.org.

Who is filling out this form?

Your First Name

Your Last Name

Your Email Address

Your Relationship to the Youth

Your Phone #

By providing your phone number, you agree to receive text messages from Project Avary. Message and data rates may apply. Message frequency varies. Reply STOP to cancel anytime. View our Terms of Service and Privacy Policy.

Does the youth meet the following criteria (please check all that apply)

The youth has a caregiver who is or was incarcerated, arrested, detained by ICE, or deportedThe youth is between the ages of 8-18 years oldThe youth does not meet some of the above criteria, but I would still like them to be considered. (Youth are enrolled on a case-by-case basis.) Please call/text 510-609-6925 or email ahtziri@projectavary.org if you have questions before filling out this form

Adult Caregiver Details

Adult Caregiver First Name

Adult Caregiver Last Name

Adult Caregiver Phone #

Adult Caregiver Email Address

Adult Caregiver's Relationship to Youth

Relationship Explanation

Adult Caregiver's Preferred Language

Are there other youth in the household applying?

Lastly, in a few words, please tell us why Project Avary would be a good fit for the above youth?