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Application Information
Application Information
*
entry or selection is required
.
First Name:
*
MI:
Last Name:
*
Date of Birth:
*
Email:
*
Cell Phone:
*
How would you prefer to be contacted?
*
Call
Text
E-mail
Traditional Mail
If phone preferred, best time to call:
Have HS diploma/GED?:
*
Yes
No
Select your gender:
*
Female
Male
Ethnicity:
*
American Indian or Alaska Native
Asian
Native Hawaiian or Pacific Islander
Black or African American
Hispanic
White
Multi-Racial
Other
Prefer not to provide
Address:
*
City:
*
State:
*
Zip Code:
*
Parent/Guardian Name 1:
Relation:
Hm Phone#:
Wk Phone#:
Parent/Guardian Name 2:
Relation:
Hm Phone#:
Wk Phone#:
Who is requesting this information?
*
Applicant
Parent/Guardian
Other
If "Other", please specify:
How did you find out about ChalleNGe?
Another applicant told Me
From an AMYA Graduate
From a family member
From friends at school
From school staff or school counselor
From a social worker, probation officer, etc.
From a paper advertisement (Brochure, Mail Out)
From TV or the radio
Other – Please describe in next box
If other, please describe:
