Referred By:(Required) Cherry Street Mission A Renewed Mind Harbor Zepf Unison Radio TV Social Media Word of Mouth Other APPLICANT'S INFORMATIONName(Required) First Last Mailing Address Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email(Required) Phone(Required)Date of Birth(Required) MM slash DD slash YYYY BREAKING DOWN BARRIERS & GETTING TO KNOW YOUDo you have a High School Diploma or GED? HS Diploma GED None Are you interested in support for GED prep? Yes No Do you have reliable transportation to attend class / employment? Yes No My means of transportation is: Do you need transportation assistance? Yes No Do you have barriers to success you would like help addressing? Yes No Do you have any felonies?Your answer will not affect eligibility for most programs Yes No Type Are you currently employed? Yes No Days/TimesWhat barriers are keeping you from being employed?Would you like help pursuing employment before class starts? Yes No Which class are you interested in?(Required) Auto Tech Building Trades Culinary Office Specialist Job Search GED Tutoring Pre-GED Welding Tool and Die Food Truck Operations After you graduate, what are your career goals?Rate your motivation for starting a career after graduation (10 being the strongest)Is your household income less than 200% of the Federal Poverty Guidelines? (Verification will be required during registration) Yes No CAPTCHA Δ
