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GENESIS Program Application
Application must be completed prior to intake meeting
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* Indicates required question
Email
*
Your email
Date
*
MM
/
DD
/
YYYY
Student Name:
*
Your answer
Date of Birth
*
MM
/
DD
/
YYYY
Address
*
Your answer
Parent contact information: Phone and Email
*
Your answer
Name of current school attending:
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Your answer
Year of Graduation
*
Your answer
Credits earned to date
Your answer
Do you currently receive services under an IEP or 504?
*
IEP
504
I do not receive services
Case Manager Name
*
Your answer
School Counselor Name
*
Your answer
Why do you want to consider enrollment in the Genesis Program?
*
Your answer
What do you consider to be your academic strengths?
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Your answer
What have been some of the barriers for you in your current program?
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Your answer
What are your goals and how do you think the Genesis program will help you reach them?
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Your answer
The next step will be an interview/intake meeting with you building administrator, school counselor, Genesis team and family . What days and times work best for you?
*
Your answer
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