CORE Program Application

Program Application
This application will help us determine your motivation to join the program and what you hope to accomplish. Please complete each item. Blank or incomplete applications will not be accepted. All information is confidential.
First Name, Last Name
Todays Date

MonthDayYear
Date
Street
City
State
Zip
Home Telephone
Cell Phone
Email
example@example.com
How old are you?*
What is your date of birth
Are you now or have you ever been in foster care?*
Are you now or have you ever been homeless
Household Monthly income bracket:*
Household size*
Emergency Contact Name
Emergency Contact Phone
Where did you hear about our program*
Are you currently attending school?*
Date last atttended
Highest grade completed
Why did you drop out?
Why are you interested in this program*
Select all programs you are interested in:

ConstructionCulinaryHealth Care/CNAPaid job training (conservation corps)Solar InstallationEntrepreneurshipHospitalityMedia and Creative ArtsCollege AdmissionMilitary Enlistment
Are you registered to vote
Do you know how to drive
Do you have a valid Drivers License
Do you have a drivers Permit
Do you have a car
Have you ever been in a training program?*
If so what program
Dates Attended
Did you complete the program?
Additional Program Name
Date attended
did you complete the program
Are you Employed?*
Hours worked per week
If unemployed, date most recent job ended
Are you looking for work?
Do you have a resume
Do you have children/ dependents of your own?
If so how many
Do they live with you?
Have you ever been arrested
Do you currently have a case pending?
Have you ever been convicted of a misdemeanor?
Have you ever been convicted of a felony?
Have you ever been convicted of a crime?
If yes, please describe and include dates and status of the case
Are you on probation/parole?
I attest that the information provided in the application is accurate and true and understand it is used to assess my interest and abilities to complete the program. CORE a Community Collaboration does not share any of this information with outside agencies unless authorized by you. Furthermore, CORE does not discriminate based on race, religion, sexual orientation, disability, or any other reason.
Signature

Clear
Date

MonthDayYear
Date
Parent Name if student is under 18 years of age
Parent Cell phone
Parent Email
example@example.com
Parent Signature

Clear
Date

MonthDayYear
Date
Should be Empty: