Student Enrollment Application

Who is referring the Student? (Only Select One) *

Self (Potential Student)

Family Member or Friend

Partner or Organization

Which program are you interested in? Select all that apply. *

8MSEd (G.E.D. Program)

8MS Works (Job Training)

Sons of Promise (Boys Mentoring Program)

Referring Name

First Name

Last Name

Phone

(###)

###

####

Student Name *

First Name

Last Name

Student Phone

(###)

###

####

Student Date of Birth *

MM

DD

YYYY

Student Race *

Asian

Black/African American

White

Hispanic or Latino

American Indian or Alaskan Native

Native Hawaiin or Pacific Islander

Middle Eastern or North African

other

Student Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Are You Currently Employed? *

Yes

No

Actively Looking

How Many Hours Do You Currently Work Weekly? *

I am not currently employed

1-10 Hours

11-20 Hours

21-30 Hours

31-40 Hours

41+

Parent/Guardian /Emergency Contact Name *

First Name

Last Name

Parent/Guardian/Emergency Contact Phone *

(###)

###

####

Parent/Guardian Income Range *

Below $10,999

$11,000-$40,999

$41,000-$60,999

$61,000-$80,999

$81,000-$100,999

Above $101,000

This is the Emergency Contact

Parent/Guardian Race *

Asian

Black/African American

White

Hispanic or Latino

American Indian or Alaskan Native

Native Hawaiin or Pacific Islander

Middle Eastern or North African

other

Parent/Guardian Ethnicity *

Hispanic or Latino

Not Hispanic or Latino

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

How Did You Initially Hear About Us? (Only Select One) *

Social Media

Community Event

Flyer/QR Code

Former Student

Search Engines (other websites, blogs, etc.)

Other

*

*By checking this box, you consent to receive emails and text communications for 8MS.