Program Application
*Note- Participants will have 90 days from their Orientation date to complete enrollment. If enrollment is not complete within 90 days, participants will need to start the orientation & enrollment process again.
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Email *
First Name *
Middle Initial *
Last Name *
Preferred Name (if different from above)
Sex Assigned at Birth *
Gender Identity *
Required
Preferred Pronoun(s)
By answering this, you permit us to use your selected pronoun at the Next Generation Zone to include the Career Connected Classroom, Zoom meetings, phone calls, or in-person conversations with parents/guardians, etc. If you would like to clarify this or have specifics you would like to discuss; please indicate this by selecting, "I would like to discuss my pronouns with the Academic Life Coach."
Preferred Pronoun(s) (this lets us know how you would like to be referred to) *
Required
Date of Birth *
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Age *
Primary Language *
Street Address *
City, State, Zip *
Contact Phone *
Email Address *
Preferred method of contact *
Do you have health insurance? *
Do you have a primary care physician? *
In an emergency, please notify: (Name, Phone, Relationship) Contact 1 *
In an emergency, please notify: (Name, Phone, Relationship) Contact 2 *
In case of injury or sudden illness, I hereby give permission to any hospital or doctor to render immediate emergency aid as might be required at the time to ensure my health and safety. Please type your name below. *
Do you have a state-issued ID? *
Country of Birth: *
Parent/Guardian Name: *
Parent/Guardian Phone Number *
Which categories describe you best (select all boxes that apply, you may select more than one) *
Required
Are you married? *
Are you either homeless or a runaway? *
Do you have dependents (children)? *
Have you been in foster care? *
Are you or have you been involved in the justice system? *
If yes, what is your PO's name?
Do you have a job? *
If yes, full time or part time?
Clear selection
Are you looking for work? *
Does either parent/guardian have a high school diploma? *
Does either parent/guardian have an Associate's Degree? *
Does either parent/guardian have a Bachelor's Degree? *
Do you have any physical impairment? *
Have you ever had an IEP or 504 plan? *
If yes, which one?
How long do you think it will take you to get your GED? *
How did you hear about our program? *
Required
Are you associated with any gangs? *
Are you a registered or unregistered Sex Offender? Individuals convicted of sex or kidnapping offenses are required to self-disclose such status to the Open Doors Program Manager prior to admission as a condition of enrollment. Failure to comply may be grounds for denial of admission or expulsion from the Open Doors Reengagement GED Program. *
School last attended: *
Highest grade completed: *
I consent to the use of confidential information about me within the Open Doors GED classroom to plan, provide, and coordinate services for me or for other purposes authorized by law. I further grant permission to the Open Doors GED classroom and the Next Generation Zone staff to use my confidential information (i.e., high school transcripts or other educational records beyond just “directory information”) and disclose it to each other for these purposes. Information may be shared verbally or by computer data transfer, mail, email, or hand delivery. *
Participant Signature *
Date *
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