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Milagro House Application
Demographic Information and Resident/Non-Resident Determination
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* Indicates required question
Name
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Age
*
Your answer
Phone Number
*
Your answer
Email
Your answer
Ethnicity
*
Hispanic/Latino
Non-Hispanic/Latino
Client doesn't know
Prefer not to answer
Primary Race
*
American Indian or Alaskan Native
Asian
Black or African American
White
Native Hawaiian or Pacific Islander
Prefer not to answer
Current Address
*
Your answer
Who referred you to Milagro House?
Your answer
Which program are you applying for?
*
Residential GED or Post-Secondary Programs
Non-Residential GED Classes
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