K House Nomination Form

Moving youth from surviving to thriving through educational pathways to a sustainable life.

K House is a partnership effort between public colleges and universities and a youth service provider (YSP) to create a living and learning community for youth - under age 25 - who identify as unaccompanied, homeless, and/or formerly in foster care and aspire to attend and graduate from college. The house is named for Stan Kaszanek, a champion of housing for people who had experienced homelessness.

If you have any questions, feel free to contact Jonathan Regis, Program Director of YouthHarbors, at 617-716-9215 or jregis@jri.org.

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* 1. Today's Date

Date

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* 2. Who is making this nomination?

Youth Self-referral

Community Member

College/University faculty

College/University staff

K House affiliate

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* 3. Youth's First Name, Middle Initial, Last Name

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* 4. Youth's Date of Birth

D.O.B.

Date

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* 5. Youth's Gender Pronouns

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* 6. Youth's Phone Number

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* 7. Youth's Email address

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* 8. Public College/University Youth Currently Attends:

Bunker Hill Community College

Roxbury Community College

Massachusetts College of Art & Design (MassArt)

University of Massachusetts Boston

Other (please specify)

None of the above

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* 9. Youth applied for Admissions to

Bunker Hill Community College

Roxbury Community College

Massachusetts College of Art & Design (MassArt)

University of Massachusetts Boston

Other (please specify)

None of the above

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* 10. Is this youth (check all that apply)

Currently homeless (couch surfing, moving from house to house, living in a car, sleeping in a library, etc.)

Currently living in a shelter

Foster Care involved

Formerly Foster Care involved

Housing insecure (e.g.: has history of temporary living arrangements)

In need of emergency housing