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Community Violence Intervention Program
Mind Your Mental
Promoting Employment Opportunities for Survivors of Trafficking (PEOST) Initiative
SMART (Support, Mindset, Attitude, Respect, and Teamwork)
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2026 Placement Site Application
Liability Consent Forms (Printable PDF)
Mindset Kidz’s Program Timesheet
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Home
About
Programs & Services
Programs
Community Violence Intervention Program
Mind Your Mental
Promoting Employment Opportunities for Survivors of Trafficking (PEOST) Initiative
SMART (Support, Mindset, Attitude, Respect, and Teamwork)
Services
Youth Services
Family Services
Community Violence Intervention Services
Training and Education
Forms
2026 Placement Site Application
Liability Consent Forms (Printable PDF)
Mindset Kidz’s Program Timesheet
Travel Consent Form
Gallery
Shop
Shop
Cart
My Account
Support
Contact
Facebook
Instagram
Youtube
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Mindset Kidz’s Placement Site Application
Please email leadcommunitycenter@gmail.com with questions or for additional information.
Organization Name
*
Field/Industry
Which Field/Industry applies to your organization? (Check all that apply.)
*
Barbershop
Cosmetology
Education
Human Services
Childcare
Food Services/Cooking
Law Enforcement/Legal Services
Construction
Entertainment
Health Care
Property Management
Mechanics
Animal Care
Other
If other please lis the field/industry that applies to your organization.
*
What does the organization do (mission statement, services provided, etc.)
*
Primary Contact Name
*
First
Last
Primary Contact Email
*
Email
Confirm Email
Telephone Number
*
Ex.555-555-5555
Where is the job site located (city/county)
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Has a participant been mentored at your organization in previous years?
*
Yes
No
Not Sure
Number of participants requested by your organization?
*
Name of Direct Supervisor
*
First
Last
Direct Supervisor’s Job Title
*
Direct Supervisor’s Email Address
*
Email
Confirm Email
Mentor/Direct Supervisor’s Telephone Number
*
Please Read
Please take the time to provide accurate, specific, and concise information. Program participants will use this information to apply for projects. Remember, your project must offer them opportunities to develop as leaders, build upon existing skills, learn new skills, and explore career options.
Assigned Position
*
Participant’s assigned role/ position at your organization.
Has this project been conducted previously?
*
Yes
No
Skillset desired (list any skills needed to successfully complete the project)
*
Tasks to be Performed by the participant(s)
*
Ex. Filing paperwork, organizing documents, and maintaining orderly records. Assisting with social media content creation. Supporting staff with logistics such as printing, organizing supplies, or assembling kits.
Please indicate how your project can be completed
*
100% teleworking/virtual
100% in person
Hybrid
Anticipated work schedule (check all that apply)
*
Weekdays (M-F)
Weekends
Evenings
Is there anything else you would like to tell us that might be relevant to the participants when choosing which job site they would prefer:
*
GDPR Agreement
*
I consent to having this website store my submitted information so they can respond to my inquiry.
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