Participant Application
Full Name
*
Prefix
First Name
Middle Name
Last Name
Suffix
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
What race do you identify with?
*
Please Select
African American
White
Hispanic
American Indian or Alaska Native
Asian
Native Hawaiian or Other Pacific Islander
Gender
*
Please Select
Male
Female
Age
*
E-mail
*
If you are under 18, please provide your parent's e-mail address.
Cell Phone
*
Home Phone
*
Email
*
example@example.com
Preferred Method of Contact
*
Home Phone
Cell Phone
E-mail
Shirt Size
*
Boy
Girls
Men
Women
Small
Medium
Large
XL
2X
3X
Shirt Size
*
Please Select
Adult Small
Adult Medium
Adult Large
Adult XL
Adult 2X
Adult 3X
Which program are you interested in.
*
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Tell us about yourself
Please answer all questions
Tell us a little about yourself.
What are some of your hobbies?
List 3 of your life goals.
What do you think your purpose is in life?
What are some areas in life, work or school that you face challenges in?
When you are upset or dislike a certain treatment how do you generally respond.
Have you ever been convicted of a crime? Do not include convictions that were sealed or expunged pursuant to a court order.
Yes
No
if yes please answer here
Are you currently on supervised probation or parole?
Yes
No
if yes please answer here
Have you ever had suicidal thoughts, currently having suicidal thoughts or felt/feeling depressed?
Yes
No
if yes please answer here
Are you currently taking medication for depression or other mental conditions?
Yes
No
if yes please answer here
Are currently using drugs or alcohol? If yes please list names below.
Yes
No
if yes please answer here
Do you currently have children or taking care of children?
Yes
No
if yes please answer here
Are you currently receiving any type of Government Assistance?
Yes
No
What benefits do you currently receive.
Please upload a copy of your award letter.
Do you currently have reliable transportation?
Yes
No
Are you currently in programs that require you to obtain community service hours?
Yes
No
if yes please answer here
Emergency Contact
Name
First Name
Last Name
Phone Number
Please enter a valid phone number.
Email
example@example.com
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Submit Form
By submitting the form, I, as the parent/guardian of the registrant, I hereby give consent for him/her to be registered by the agency
By submitting the form, I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the New Nation Center LLC, its affiliated organizations, and sponsors. Recognizing the possibility of physical injury associated and in consideration for the New Nation Center LLC, accepting the registrant for its programs and activities (the "Programs"). I hereby release, discharge, and/or otherwise indemnify the New Nation Center LLC, its affiliated organizations and sponsors, their employees, and associated personnel, against any claim by or on behalf of the registrant as a result of the registrant's participation in Programs and/or being transported to or from the same, which transportation I hereby authorize.
Signature for those under the age of 18 please have parents sign and and submit.
*
Submit Form
Submit Form
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