Connect-Us Program Application

Please fill out the application below, and we will get back to you ASAP with next steps.

Questions?
Email plewis@connectusct.org
Call or text: 203-864-9129

Program you're applying for: *
You can select more than one.
Name *
Name
Gender *
Home phone
Home phone
Cell phone
Cell phone
Best way to reach you *
Put "N/A" if you're not in school.
Ex. Freshman, Sophomore, Junior, Senior. Put "N/A" if you're not in school.
Put "N/A" if you're not in school.