E3 Power Center City | JEVS Human Services

Thank you for your interest in E³ Power Center City. The E³ Power Centers are a neighborhood-based, holistic approach to preparing out-of-school youth (ages 16-21) for the achievement of long-term educational, career and personal goals, including self-sufficiency.

Completion of this referral form is the first step in the enrollment process and is not a guarantee of acceptance.

Upon receiving your referral, the E³ Enrollment Coordinator will contact you shortly to discuss the program, enrollment process and any other eligibility requirements.

Are You Referring Yourself or Someone Else to E3?*

Myself
Someone Else

Your First Name*

Your Last Name*

Agency or Office, if Appropriate

Phone Number*

Email*

First Name of Youth*

Last Name of Youth*

Age of Youth*

Phone Number of Youth*

Email of Youth*

Is Youth a Philadelphia Resident?

Yes
No

Does Youth Have a High School Diploma or GED?

Yes
No

Current Street Address*

Street Address City State ZIP Code

How Did You Hear About E3 Power Center City?*

If Other, how?

Do You Have a Pennsylvania ID Card or Driver's License?*

Yes
No

Do You Have a Social Security Card?*

Yes
No

Do You Have a Birth Certificate?*

Yes
No

Why Are You Interested in E3 Power Center City?*

By clicking the “Submit” button, I give E³ Power Center City permission to contact me only about their programs using the above phone number and email address.

Email

This field is for validation purposes and should be left unchanged.