STUDENT APPLICATION
How did you hear about us?
*
Please Select
Flyer
Outdoor Signage
Friend/ Family
Facebook
Instagram
Radio
TV
Other
What are you interested in learning? Select all that apply.
*
Job Skills (i.e. computer literacy, interviewing, resume development, etc)
Life Skills (i.e. goal setting, communication, confidence, conflict resolution, etc)
Spiritual Development
Do you have a High School Diploma or GED?
*
Please Select
Yes
No
Section 1: Personal Information
Name
*
First Name
Last Name
Middle Name (type none if you do not have a middle name)
*
Date of Birth:
*
-
Month
-
Day
Year
Date
Cell Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
I certify that the information I have provided in this document is true, accurate, and complete to the best of my knowledge. I understand that any false, misleading, or omitted information may result in the denial for participation in this program.
Type your Signature and click Submit
*
Submit
Staff Use Only
Referred to get GED?
Please Select
Yes
No
Interview
Scheduled
Completed
Interviewer
First Name
Last Name
Basic Computer Skills Eval
Please Select
Yes
No
Computer Skills Level
5 of 6
Upload Driver's License or State Issued ID
Browse Files
Drag and drop files here
Choose a file
Cancel
of
Background Check Submitted
-
Month
-
Day
Year
Date
Background Check Passed
Please Select
Yes
No
Comments
Enrolled
Please Select
Accepted
Not Accepted
Enrollment Date
-
Month
-
Day
Year
Date
Should be Empty: