What is your level of interest in the program
*
Not very interested
1
2
3
4
Very Interested!
5
1 is Not very interested, 5 is Very Interested!
Which program are you interested in?
*
Introductory Training Program (Monday evenings - 4 weeks)
Entry Level Technician Program (10 weeks)
Are you interested in a career as an automotive technician?
*
Yes
No
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STUDENT PROGRAM APPLICATION
WE DO NOT ACCEPT STUDENTS WHO ARE 26 YEARS OLD OR OLDER. Please allow up to a week for a response from your application. We will respond to your application by e-mail. PLEASE USE A VALID EMAIL ADDRESS. Please read the program details on our Program Page before filling this application out. Fill out this form if you are interested in joining one of our programs. Revised 3 May 2025.
Applicant Information and Contact Details
First Name
*
Last Name
*
Birthday
*
-
Month
-
Day
Year
Date Picker Icon
Age
*
Mobile Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Other Phone (optional)
Please enter a valid phone number.
Format: (000) 000-0000.
Personal Email
*
example@example.com
Primary Address Type
*
Home
Other
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
County (Ex: Fulton, Dekalb)
*
Please Select
Barrow
Bartow
Butts
Cobb
Cherokee
Clarke
Clayton
Coweta
Dekalb
Douglas
Fayette
Forsyth
Fulton
Gwinnett
Hall
Henry
Newton
Oconee
Paulding
Rockdale
Walton
Other
If Other, please type your county.
Do you have a valid drivers license?
*
Yes
No
Race
*
Black or African American
Native Hawaiian or Other Pacific Islander
American Indian or Alaska Native
White
Multiracial
Asian
Ethnicity
*
Hispanic or Latino
Not Hispanic or Latino
Gender
*
Female
Male
Emergency Contact (first and last name)
*
Emergency Contact Relationship
*
Mother
Father
Sibling
Other Relative
Spouse or Partner
Friend
Emergency Contact Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
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Household Information
Annual Household Income
*
$0 - $9,999
$10,000 - $24,999
$25,000 - $49,999
$50,000 - $74,999
$75,000 - $99,000
$100,000 - $149,999
$150,000 and greater
Prefer not to answer
How many people live in your household?
*
Please Select
1
2
3
4
5
6
7
8
9 or more
Is anyone in your household eligible for CHIP (Children's Health Insurance Program), TANF (Temporary Assistance for Needy Families), SNAP (Supplemental Nutrition Assistance Program) and/or WIC (Special Supplemental Nutrition Program for Women, Infants, and Children)?
*
Yes
No
Who do you currently live with?
*
Please Select
Friends
Family
I live on my own
I am currently in between homes/my housing is not stable
Unhoused
Do you have any children?
*
Yes
No
If you have children, how many and how old?
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School & Work History
Do you have a high school diploma?
*
Yes
No
Do you have another diploma or certificate? Select all that apply.
HiSet
GED
2-Year Degree
4-Year Degree
None of these options
Please select the highest grade completed.
*
Please Select
1
2
3
4
5
6
7
8
9
10
11
12
Some college
Associate's degree
Bachelor's degree
Have you had any previous automotive training? (For example, did you take any special auto shop classes in high school?) If you have experience, please describe.
*
Have you ever held a job?
*
Yes
No
Are you currently employed?
Yes
No
If yes, who is your employer?
Employment position
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Medical Information
Do you have any food allergies?
*
Yes, I do have a food allergy.
No, I do not have a food allergy.
If you answered "yes," please list food allergies.
Do you have any known physical or mental health conditions? (This information is not shared outside the organization and is for social services referrals only)
*
Yes, I do have a physical or mental health condition.
No, I do not have a physical or mental health condition.
If you answered "yes," please list physical or mental health conditions.
Do you take any prescription medications? (This information is not shared outside the organization and is for social services referrals only)
*
Yes, I do take prescription medications.
No, I do not take prescription medications.
If you answered "yes," please list prescription medications.
Can you lift a minimum of 25 pounds?
*
Yes
No
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Involvement in the Justice System
Have you previously been arrested?
*
Yes
No
If so, list the charges/convictions and when they occurred. (Should not prevent you from being selected for class.)
Do you have any tickets or violations?
*
Yes
No
If so, please list them and the dates.
Have you used illegal drugs in the past, including marijuana?
*
Yes
No
Can you pass a drug test right now?
*
Yes
No
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Additional Questions and Reference to Jumpstart
How did you hear about Jumpstart?
*
Please Select
Corner Outreach Program
Department of Family and Child Services (DFCS)
DCS Client
Family/Friends
Former Student
Fulton County Juvenile Court
Hearts to Nourish Hope
International Rescue Committee (IRC)
News
Online (Google, ads)
Online (Indeed)
Referral
School
Urban League Academy
Veterans Holding Minds
WorkSource
Other
Please describe who referred you to Jumpstart (organization name and person, name of former student, etc.).
*
How will you be getting to class?
*
Car
Rideshare or Drop-off
Public Transportation (bus, train)
Walking or biking
Are you familiar with how to use a ratchet?
*
Yes
No
What are some things you have been committed to? (ex: school sports, volunteering, etc.)
*
If you are accepted into the program, how will you show your commitment?
*
What do you think you are good at?
*
What do you enjoy in your free time?
*
Have you ever worked on a car? If so, please describe it.
When is the soonest you can start the program?
*
-
Month
-
Day
Year
Date Picker Icon
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