Program Enrollment Form 2020-2021
Note: The first email address field is used to send you a copy of your enrollment information.
Email *
For more information, please visit www.communitychangeinc.com.
All fields must be completed. Incomplete applications will not be accepted. This enrollment form must be completed and electronically signed by the parent or guardian of the student to be enrolled in the program. Once completed, please click "SUBMIT" at the bottom of the form.
Student's Legal First Name *
Middle Initial
Student's Legal Last Name *
9-digit Student’s I.D. (OSIS) *
Please include numbers only
Student’s Email *
**Cannot be student’s school email account**
Student’s Phone Number *
Must include area code
Student's Birth Date *
Please format as: 00/00/0000 or 00-00-0000
Gender *
Primary Language Spoken *
Student’s Grade in September 2020 *
Race/Ethnicity *
Student’s school – Bronx Compass High School
Student’s Club – please type the name(s) of the CareerVisions Institute club(s) the student wishes to attend. Note that the student is expected to attend these clubs each day that they are offered.
Club Name #1
Club Name #2
Club Name #3
Teacher Name #1
Teacher Name #2
Teacher Name #3
Parent/legal guardian involvement in this program Is welcomed and encouraged.
Parent/Guardian Name *
Parent’s Phone Number *
Must include area code
Parent/Legal Guardian Email *
Home Street Address (include Apt Number) *
City *
State *
Zip Code *
What are three issues that you are most concerned about in your neighborhood? *
Would you be willing to visit a group of our students for at least 30 minutes to talk about your career?
Clear selection
If yes, which career would you discuss?
What days are best for you to visit?
What times are best for you to visit?
Name / relationship to student
Best daytime #
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