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Information Request Form
If you would like to have a recruiter contact you, please provide the following information.
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* Indicates required question
Email
*
Your email
Would you like a recruiter to call you?
*
Yes
No
How did you hear about our program?
*
Internet search
Graduate/Family Referral
Social Media
Radio Ad
TV Commercial
Internet Ad
Other:
Applicant First Name
*
Your answer
Applicant Last Name
*
Your answer
Applicant Date of birth
*
01/01/2014
MM
/
DD
/
YYYY
Applicant Age
*
Must be 16 on or before the start of a class; and no older that 18 on the day the class starts.
Your answer
Mailing Address
*
123 1st St.
Your answer
City
*
Your answer
State
*
NMNGYCA is open to NM Residents ONLY
Your answer
Zip Code
*
Your answer
County
*
Your answer
Gender
*
Male Or Female
Male
Female
Required
Applicant Race
American Indian or Alaskan Native
Asian
Native Hawaiian or Pacific Islander
White
Black or African America
Other
Clear selection
Parent/Guardian Information
Please provide contact information for at least one parent/guardian.
Parent/Guardian First Name
*
Your answer
Parent/Guardian Last Name
*
Your answer
Relationship:
*
Father, Mother, Guardian
Your answer
Phone Number
*
(555)-555-5555
Your answer
Parent/Guardian Email Address
*
example@domain.com
Your answer
Preferred method of communication:
*
Phone
Email
Other:
Best time to call?
*
Your answer
Questionaire
Please answer the following questions as truthfully as possible.
Applicant's Statement: Please state why you desire to be accepted to the ChalleNGe program?
*
Your answer
Do you meet one or more of the following? (check all that apply)
*
Habitually truant
Drop out
Expelled
Behind in credits
16-18 yrs
Currently on or ever been on probation
Have valid NM ID
Voluntarily applying
Required
Have you ever been adjudicated, indicted, or charged with a crime considered a felony?
*
Yes
No
If yes, please explain. (Court/JPO documentation is required for consideration for acceptance.
Your answer
Have you ever been or are you currently under the care of a counselor or therapist?
*
Please leave your comment or question here
Yes
No
If yes, please provide name and number of counselor or therapist.
*
Your answer
Do you currently have any medical concerns that could keep you from participating in our program?
Yes
No
Clear selection
If yes, please explain.
Your answer
How did you find out about the ChalleNGe?
*
Your answer
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