2023-2024 JAG Application

JAG College Success Program Application Form
Name

First NameLast Name
Student ID
Date of birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

City/StateState / Province

Postal / Zip Code
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Preferred contact method: (select all that apply)

Phone callTextEmailOther
Emergency contact name
First & Last
Relationship
Emergency Contact Address

Street Address

Street Address Line 2

City/StateState / Province

Postal / Zip Code
Emergency Contact Phone number
School and Work Plans for the 2023-24 year (check all that apply)

Work full-time.Attend school part-timeWork part-time.Attend school full-time
Area of study/ Major
Needs Assessment and Qualifications

The following questions are required for the National JAG Database for data purposes only. All information will be kept confidential.
Which of the following best describes your current living situation?

Live with Both ParentsLive with FriendsLive with MotherLive by MyselfLive with FatherLive with PartnerLive with RelativeLive with Foster ParentsOther
Number of persons in family or household including yourself
Are you eligible for Temporary Assistance for Needy Families (TANF)?

YesNoNot Sure
Do you have your own vehicle?

YesNo
Select all that apply to you:

Currently or Previously Enrolled in JAG High School ClassBeen Convicted of a Criminal Ofense (other than a traffic violation)Have a Documented Alchohol and/or Substance AbuseFather has Completed 4 Year College DegreeNeither Parent has Completed 4 Year College DegreeMother has Completed 4 Year College DegreeHave a Documented DisabilityA Parent or Expecting ParentHave a Record of Violent BehaviorBoth Parents have Completed 4 Year College DegreeEnglish LearnerHave Poor Attendance Record
Students enrolled in the JAG Program must accept and adhere to the following conditions

Attendance of monthly JAG meetings and workshopsMonthly check-in with JAG CoachDisclosure of changes in work or living arrangements
By signing this, I certify that to my knowledge, the above form has been filled out completely and accurately. I agree to provide the appropriate documentation to the SouthArk JAG College Career Coach
Signature

Clear
Date

MonthDayYear
Date
Should be Empty: