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GBCS AJCC 2024-25 High School Lottery Registration Form
Once your application is complete, please take the following steps.
1. Orientation is every Monday at 8am. Please coordinate with Job Corp campus to check when you are scheduled to come in with the group.
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* Indicates required question
Today's Date
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MM
/
DD
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YYYY
Are you currently residing on Job Corps Campus?
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Yes
No
Student Name: (First, Middle and Last)
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Your answer
If student has gone by any other legal name please list below.
Your answer
Student Physical Address:
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Your answer
Student Mailing Address if different than Physical Address
Your answer
Student Date of Birth:
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MM
/
DD
/
YYYY
Email:
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Your answer
Person completing this form
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Student/Self (only if over 18)
Parent/Guardian
Other:
Required
If student is under 18, please provide parent/guardian name and contact information. Please include: Physical address, city, state and phone numbers.
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Your answer
Name of emergency contact: What relationship to the student: phone number: physical address, city and state
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Your answer
Student Phone Number (include area code)
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Your answer
Secondary Phone Number (include area code)
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Your answer
Please provide us with the contact information of a friend or family member we can leave a message with if we cannot reach you.
Provide a
NAME, RELATIONSHIP, PHONE #, EMAIL, SOCIAL MEDIA
information below.
*
Your answer
Ethnicity
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Hispanic
Non-Hispanic
Race
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Asian or Pacific Islander
Black or African American
White or Caucasian
American Indian or Alaskan Native
Other: (please indicate)
If American Indian or Alaskan Native, please specify tribe:
Your answer
What is the last school you attended? (include city and state)
*
Your answer
Gender:
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Female
Male
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