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<!DOCTYPE html PUBLIC "-//W3C//DTD XHTML 1.0 Transitional//EN" "http://www.w3.org/TR/xhtml1/DTD/xhtml1-transitional.dtd"> <html xmlns="http://www.w3.org/1999/xhtml" xml:lang="en-US" lang="en-US"> <head id="Head"> <SCRIPT language="JavaScript"> <!-- window.location="http://dfcs.dhr.georgia.gov/teenwork"; //--> </SCRIPT> <meta id="MetaDescription" name="DESCRIPTION" content="Georgia TeenWork " /> <meta id="MetaKeywords" name="KEYWORDS" content="" /> <meta id="MetaCopyright" name="COPYRIGHT" content="Copyright 2008 TeleVox" /> <meta id="MetaAuthor" name="AUTHOR" content="Georgia Teen Work " /> <meta name="RESOURCE-TYPE" content="DOCUMENT" /> <meta name="DISTRIBUTION" content="GLOBAL" /> <meta name="ROBOTS" content="INDEX, FOLLOW" /> <meta name="REVISIT-AFTER" content="1 DAYS" /> <meta name="RATING" content="GENERAL" /> <meta http-equiv="PAGE-ENTER" content="RevealTrans(Duration=0,Transition=1)" /> <style id="StylePlaceholder" type="text/css"></style> <link 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src="/ScriptResource.axd?d=ySUg8gnbfxDy5H7ppmA5vnZZyjM9-n1aYwf3N4kkTN83PAAplHRZzXOxN1UT2_YEIfNvmSuTCEg1&t=633543191274348450" type="text/javascript"></script> <script type="text/javascript"> //<![CDATA[ function WebForm_OnSubmit() { if (typeof(ValidatorOnSubmit) == "function" && ValidatorOnSubmit() == false) return false; return true; } //]]> </script> <script src="http://tools.televoxsites.com/js/jquery/jquery-1.2.6.min.js" type="text/javascript"></script> <script type="text/javascript"> var DNN_skinPath = "/Portals/_default/Skins/siteskin_new/"; jQuery.noConflict(); </script> <script src="http://tools.televoxsites.com/js/sifr3-436/sifr.js" type="text/javascript"></script> <script src="http://tools.televoxsites.com/js/swfobject.js" type="text/javascript"></script> <script src="js/jquery.cycle.all.min.js" type="text/javascript"></script> <script src="js/site.js" type="text/javascript"></script> <div id="shell"> <div class="content"> <span class="headeraddress">Two Peachtree Street, NW Suite 18-213 Atlanta, Georgia 30303</span> <a href="http://www.georgiateenwork.org" id="logo">Georgia TeenWork</a> <div id="socialnetworking"> </div> <div id="iconnav"> </div> <div id="pinknav" class="topnav"> <iframe src="menu_header.html" frameborder="0" width="670px" height="45px"></iframe> </div> <a href="#sharearea" id="sharebtn">share</a> <div id="sharearea"> <div id="dnn_formpane"> <a name="497"></a> <div id="dnn_ctr497_ContentPane" class="DNNAlignleft"><!-- Start_Module_497 --> <div id="dnn_ctr497_ModuleContent"> <div id="dnn_ctr497_FormMaster_pnlForm"> <table align="Center" class="" border="0" style="width:400px;"> <tr> <td id="dnn_ctr497_FormMaster_tdFormMasterHeaderCell"></td> </tr> <tr> <td Align="center"> <table id="dnn_ctr497_FormMaster_A_friend_would_like_to_share_a_link_with_you" cellspacing="0" cellpadding="0" border="0" style="border-collapse:collapse;"> <tr> <td valign="top" colspan="1" rowspan="1"> <label for="dnn_ctr497_FormMaster_ctl__20090625T165730" id="dnn_ctr497_FormMaster_lbl_ctl__20090625T165730" class="lb"> Your Name*<br> </label> <input name="dnn$ctr497$FormMaster$ctl__20090625T165730" type="text" id="dnn_ctr497_FormMaster_ctl__20090625T165730" tabindex="1" class="tx" /> <span id="dnn_ctr497_FormMaster_rfv__20090626T102018" class="NormalRed" style="display:none;"> <br>A value is required </span> </td> </tr> <tr> <td valign="top" colspan="1" rowspan="1"> <label for="dnn_ctr497_FormMaster_ctl__20090626T074129" id="dnn_ctr497_FormMaster_lbl_ctl__20090626T074129" class="lb"> Your Email*<br> </label> <input name="dnn$ctr497$FormMaster$ctl__20090626T074129" type="text" id="dnn_ctr497_FormMaster_ctl__20090626T074129" tabindex="1" class="tx" /> <span id="dnn_ctr497_FormMaster_rfv__20090626T074129" class="NormalRed" style="display:none;"><br>A value is required</span> <span id="dnn_ctr497_FormMaster_rev__20090626T074151" class="NormalRed" style="display:none;"><br>A valid email is required</span> </td> </tr> <tr> <td valign="top" colspan="1" rowspan="1"> <label for="dnn_ctr497_FormMaster_ctl__20090626T074321" id="dnn_ctr497_FormMaster_lbl_ctl__20090626T074321" class="lb">Friend's Email*<br> </label> <input name="dnn$ctr497$FormMaster$ctl__20090626T074321" type="text" id="dnn_ctr497_FormMaster_ctl__20090626T074321" tabindex="1" class="tx" /> <span id="dnn_ctr497_FormMaster_rfv__20090626T074321" class="NormalRed" style="display:none;"><br>A value is required</span> <span id="dnn_ctr497_FormMaster_rev__20090626T074351" class="NormalRed" style="display:none;"><br>A valid email is required</span> </td> </tr> <tr> <td valign="top" colspan="1" rowspan="1"> <label for="dnn_ctr497_FormMaster_ctl__20090626T074002" id="dnn_ctr497_FormMaster_lbl_ctl__20090626T074002" class="lb">Your Message<br></label> <textarea name="dnn$ctr497$FormMaster$ctl__20090626T074002" rows="4" cols="30" id="dnn_ctr497_FormMaster_ctl__20090626T074002" tabindex="1" class="tx"></textarea> </td> </tr> <tr> <td valign="top" colspan="1" rowspan="1"> <input name="dnn$ctr497$FormMaster$ctl__20090626T074746" type="text" id="dnn_ctr497_FormMaster_ctl__20090626T074746" tabindex="1" class="tx modify" /> </td> </tr> <tr id="dnn_ctr497_FormMaster_trCaptchaRow"> <td id="dnn_ctr497_FormMaster_tdCapthcaCell" align="center" colspan="1" style="padding:5px;"> <div class="Normal"> <img src="/DesktopModules/Code5Systems_FormMaster/ImageChallenge.captcha.aspx?captcha=875DC3138C260D824D7A3E3E998B0931FC3CD9D243DE6B1DB77B625A2CDE19DC95D35CB659587CE258C15FE45F11B4EACFDE4FCFE396E7C8DD2D741ABEA10F2E1C34ED2D9FE262BCCC44DB7F3570AAE13935EDF5B0123F751B4516058C4D8A519229D70FE9AD91DB12675F86118592E41793436A0F4FD722A108FAA80AC30C9C&alias=web.georgiateenwork.org" border="0" /> <div> Enter the code shown above </div> <input type="text" maxlength="6" name="dnn$ctr497$FormMaster$cpt_FormMaster" tabindex="6" value="" style="width:" /> </div> </td> </tr> <tr id="dnn_ctr497_FormMaster_trDefaultSubmitButton"> <td id="dnn_ctr497_FormMaster_tdDefaultSubmitButton" align="center" colspan="1" style="padding:5px;"> <a id="dnn_ctr497_FormMaster_cmdSubmit" class="CommandButton" href="javascript:WebForm_DoPostBackWithOptions(new WebForm_PostBackOptions("dnn$ctr497$FormMaster$cmdSubmit", "", true, "2218d646-ac7b-4989-924d-6b1c06770993", "", false, true))">Submit</a> </td> </tr> <tr> <td align="center" valign="middle" colspan="1" style="padding:5px;"> <span id="dnn_ctr497_FormMaster_lblRequired" class="normal">* Required</span> </td> </tr> </table> </td> </tr> </table> </div> <!-- End_Module_497 --> </div> </div> </div> <a id="closebtn" href="javascript:;">close</a> <script type="text/javascript"> formLink("http://web.www.georgiateenwork.org"); </script> </div> <h1 class='pagetitle'> </h1> <div id="dnn_ContentPane" class="maincontent"> <img src="images/Titles_application_for_eligible_youth.jpg" width="469" height="24" /><span id="dnn_ctr438_ViewHTMLArchive_ViewHTMLArchive_lblContent"><br /> <strong>The Department of Human Services TeenWork Program </strong></span> <div id="dnn_ctr486_ContentPane" class="DNNAlignleft"> <!-- Start_Module_486 --> <div id="dnn_ctr486_ModuleContent"> <h2 align="left"><a href="outside_link_fyi.html">This form is only to be completed by foster youth who have completed job readiness training programs. Please do not complete this form if you have not done the appropriate training, as you are not yet eligible. To become eligible, contact your ILC by clicking here.</a></h2> <p align="left"> <style type="text/css"> <!-- .red { color: #F00; } --> </style> </head> <script>function attivaPrimo() { }</script> <body id="bodyid_01" onLoad="attivaPrimo();" centermargin=0 topmargin=0 marginwidth=0 marginheight=0 > <center> <table id="Table_01" width="80%" height="599" cellpadding=0 cellspacing=0 align="center"> <tr> <td width="100%" align="center"> </td> </tr> <tr> <td align="center" valign="top" width="100%"> <table id="Table_02" height="450" width="920" border="1" background="images/bck_green.jpg" bordercolor="" frame="" rules="none" cellpadding=0 cellspacing=0> <tr> <td valign=top align="center" width="800" height=352> <script> function trim(l_str) { var l_str_string = new String(l_str); var l_int_length = l_str_string . length; var l_str_temp = new String(''); var l_b_flag = true; for(l_int_i = 0; l_int_i <= l_int_length - 1; ++l_int_i) { if (l_b_flag == true && l_str_string.charAt(l_int_i) == ' ') { l_b_flag = true; } else { l_b_flag = false; l_str_temp = l_str_string.substring(l_int_i); break; } if (l_int_i == l_int_length - 1) { return l_str_temp; } } l_int_length = l_str_temp.length; l_b_flag = true; for(l_int_i = l_int_length - 1; l_int_i >= 0; l_int_i--) { if (l_b_flag == true && l_str_temp.charAt(l_int_i) == ' ') { l_b_flag = true; } else { l_b_flag = false; l_str_string = l_str_temp.substring(0, l_int_i + 1); break; } } return l_str_string; } function checktxt(l_str_form) { if(l_str_form){ var str1=l_str_form; var str2=trim(str1.value); if(str2.length==0) { alert("A mandatory field has not been filled. Please enter an appropriate value."); l_str_form.focus(); return false; } else { return true; } } } function checkfun() { { document.form1.submit(); } } </script> <form name='form1' method='post' action='answer_for_emer_contact.html'> <input type='hidden' value='10' name='hid_fcount'> <input type='hidden' value='en' name='lang'> <input type='hidden' value="Email ILP Director" name='hid_title'> <input type='hidden' value="Thank you for contacting ILP. Your email will be received by the ILP Director and your ILP Coordinator and either addressed directly or forwarded to the appropriate party." name='hid_topmsg'> <input type='hidden' value="Please Click On The Submit Button To Send This Email." name='hid_botmsg'> <input type='hidden' value="Thank you for your question, comment or concern. An ILP representative will get back to you as soon as possible." name='hid_subreq_msg'> <input type='hidden' value="78" name='hid_page_id'> <table border="0" cellspacing="0" cellpadding="0" > <tr> <td height="10"> <spacer type="block" height="10"> </td> </tr> </table> <table width="90%" border="0" cellspacing="0" cellpadding="0" align="center"> <tr> </tr> </table> <table width="90%" border="0" cellspacing="0" cellpadding="0" align="center"> <tr> <td background="img/base/ba2.gif" > <table width="100%" border="0" cellspacing="1" cellpadding="0"> <tr> </tr> <input type="Hidden" value="Name" name="hid_fn1"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font color="#FF0000" size="1" face="Tahoma, Verdana, Arial"></font><font face="Tahoma, Verdana, Arial" color="#000000">Name*:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <input type="text" name="txt_fn_1_1" size=20 > </font> </td> </tr> </table> </td> </tr> <input type="Hidden" value="County" name="hid_fn2"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font face="Tahoma, Verdana, Arial" color="#000000">Entire Mailing Address (Street, City, State, Zip)*:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <textarea rows="4" cols="50" name="txt_fn_4_2"></textarea> </font></td> </tr> </table> </td> </tr> <input type="Hidden" value="Email Address" name="hid_fn3"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font color="#FF0000" size="1" face="Tahoma, Verdana, Arial"></font><font face="Tahoma, Verdana, Arial" color="#000000">Email Address*:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <input type="text" name="txt_fn_3_1" size=20 > </font> </td> </tr> </table> </td> </tr> <input type="Hidden" value="Question or Feedback" name="hid_fn4"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font face="Tahoma, Verdana, Arial" color="#000000">Your Emergency*:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <textarea rows="4" cols="50" name="txt_fn_4_1"></textarea> </font></td> </tr> </table> </td> </tr> <input type="Hidden" value="Phone Number" name="hid_fn5"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font color="#FF0000" size="1" face="Tahoma, Verdana, Arial"></font><font face="Tahoma, Verdana, Arial" color="#000000">Phone Number*:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <input type="text" name="txt_fn_5_1" size=20 > </font> </td> </tr> </table> </td> <input type="Hidden" value="Phone Number" name="hid_fn5"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font color="#FF0000" size="1" face="Tahoma, Verdana, Arial"></font><font face="Tahoma, Verdana, Arial" color="#000000">Alternate Phone Number*(to ensure we can reach you in the following months:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <input type="text" name="txt_fn_5_1" size=20 > </font> </td> </tr> </table> </td> </tr> <input type="Hidden" value="Area of Need" name="hid_fn6"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font face="Tahoma, Verdana, Arial" color="#000000">Areas of Interest*:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <input type="checkbox" name="txt_fn_6_1" value="Education"> Education<br> <input type="checkbox" name="txt_fn_6_1" value="Housing"> Childcare<br> <input type="checkbox" name="txt_fn_6_1" value="Health"> Retail<br> <input type="checkbox" name="txt_fn_6_1" value="Community Resources"> Community Outreach<br> <input type="checkbox" name="txt_fn_6_1" value="Other"> Entertainment<br><input type="checkbox" name="txt_fn_6_1" value="Education"> Education<br> <input type="checkbox" name="txt_fn_6_1" value="Housing"> Government<br> <input type="checkbox" name="txt_fn_6_1" value="Health"> Hospitality<br> <input type="checkbox" name="txt_fn_6_1" value="Community Resources"> State Government<br> <input type="checkbox" name="txt_fn_6_1" value="Other"> Parks & Recreation<br> <input type="checkbox" name="txt_fn_6_1" value="Other"> Landscaping & Outdoor Jobs<br> <input type="checkbox" name="txt_fn_6_1" value="Other"> Describe Below<br> </font> </td> </tr> </table> </td> </tr> <input type="Hidden" value="Others" name="hid_fn7"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font color="#FF0000" size="1" face="Tahoma, Verdana, Arial"></font><font face="Tahoma, Verdana, Arial" color="#000000">Others:</font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <input type="text" name="txt_fn_7_1" size=20 > </font> </td> </tr> </table> </td> </tr> <input type="Hidden" value="Others" name="hid_fn7"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font face="Tahoma, Verdana, Arial" color="#000000">Do You Have a State Issued ID or Drivers License? This is Required: <a href="http://www.dds.ga.gov/FAQs/Index.aspx?FAQCategoryID=33" target="_blank"> Need One</a></font></b></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <input type="checkbox" name="txt_fn_6_1" value="Other"> Yes<br> <input type="checkbox" name="txt_fn_6_1" value="Other"> No, however, I will obtain one immediately </font> </td> </tr> </table> </td><input type="Hidden" value="Coordinator Email" name="hid_fn8"> <tr> <td align="left" valign="middle" height="45" bgcolor="#FFFFFF"> <table width="100%" border="0" cellspacing="0" cellpadding="0"> <tr> <td width="2%" align="left" valign="top"> </td> <td valign="middle" align="left" width="30%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2"><b><font face="Tahoma, Verdana, Arial" color="#000000">Coordinator Email Address*: </font></b><font face="Tahoma, Verdana, Arial" color="#000000"><span class="red"><br /> <a href="region_by_county.html" target="_blank"><strong>Click Here if You Need <br /> Your Region Number</strong></a></span></font></font></td> <td height="45" valign="middle" align="left" width="68%"><font face="Tahoma, Verdana, Arial" color="#000000" size="2"> <select name="txt_fn_8_1"> <option value="region1">Region1</option> <option value="region2">Region2</option> <option value="region3">Region3</option> <option value="region4">Region4</option> <option value="region5">Region5</option> <option value="region6">Region6</option> <option value="region7">Region7</option> <option value="region8">Region8</option> <option value="region9">Region9</option> <option value="region10">Region10</option> <option value="region11">Region11</option> <option value="region12">Region12</option> <option value="region13">Region13</option> <option value="region14">Region14</option> <option value="region15">Region15</option> <option value="region16">Region16</option> <option value="region17">Region17</option> </select> </font> </td> </tr> </table> </td> </tr> <input type="Hidden" value="10" name="hid_count"> <input type="Hidden" value="27595" name="hid_user_id"> <input type="Hidden" value="78" name="hid_page_id"> <tr> <td align="center" valign="middle" height="55" bgcolor="#FFFFFF"> <input type=button value='SUBMIT' name='Button' onclick='checkfun()' > <input type=reset value='RESET' name='Button2'><br /> <br /> <br /> </td> </tr> </table> </td> </tr> <tr> <td valign="middle" height="27" width="90%"><font face="Verdana, Arial, Helvetica, sans-serif" size="2" color="#FFFFFF" ><font face="Tahoma, Verdana, Arial"></font></font></td> </tr> </table> </form> </td> </form> </body> </html>
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