LifeLaunch – Enrollment

Goodwill Industries of Southeastern Louisiana

LifeLaunch Young Adult Program

3400 Tulane Ave. Suite 1000 New Orleans, LA 70119

Telephone (504) 456-2622 * Fax (504) 456-2698



New Case

(Recruitment Form)

Name:
Address1:
Address2:
City:
State: Zip:
Phone:
Email:
*Date of Birth:
Gender:
Ethnicity Hispanic/Latino:
Race (Choose all that apply): American Indian or Alaska NativeHawaiian Native or other Pacific IslanderAsianWhiteBlack or African AmericanNot Specified
Eligible Veteran Status: Yes, <=180 DaysNoYes, Other Eligible PersonYes, Eligible Veteran
Individual with a Disability: YesNo
*Non-Violent Offender: YesNo
*Sexual Offender: YesNo
*In Work Release Program: YesNo
Alternate Contact Name:
Alternate Contact Phone:
Referring Agency: Program Manager: Date:
CaseManager: Assigned GWI Staff: Date:
Contact Number: Census Tract #:

*Denotes required fields