Registration Form

Please complete form and submit your payment. Note that there is a $3.00 convenience fee applied to the registration cost. Please allow 24-48 hours for processing (excluding weekends/holidays)

Date of Application

Program Program Start Date

Personal Information

First Name Last Name Date of Birth (Must be 18+)

Address City State Zip Code Cell Phone

Sex Male Female Trans Female (male to female) Trans Male (female to male)

Email Address

Educational Experience

Highest Level of School Completed Did you graduate from high school? Did you graduate from college? Who is your current employer? If applicable, what is their phone number? Emergency Contact Information (Please include name, relationship, phone number, and address)

Criminal Background Information

Have you ever been arrested? If yes, why? Were you convicted?

Do you have a misdemeanor? Yes No

Do you have a felony? *Please note that felons will be rejected* Yes No

Have you ever been expunged or pardoned of a crime? If yes, please further explain.

Health Background

Are you on any medications? If yes, what are they? Do you have a medical diagnosis? If yes, what is your diagnosis? Would your diagnosis affect your performance in the program? If so, in what manner? Registration Fee (Non-refundable deposit)

Submitting this form, I declare that the information contained in this application is true and complete. If information is false, I will be expelled.

Please upload a copy of your state issued ID.

Voucher Code