GOODLAND POTENTIAL STUDENT PRELIMINARY ELIGIBILITY QUESTIONNAIRE
POTENTIAL STUDENT PRELIMINARY ELIGIBILITY QUESTIONNAIRE
GOODLAND CURRENTLY ONLY ACCEPTS STUDENTS YOUNG MEN AGES 10 - 13
DATE *
MM
/
DD
/
YYYY
NAME OF LEGAL GUARDIAN.
APPLICANT NAME (IF DIFFERENT FROM LEGAL GUARDIAN). *
APPLICANT'S RELATION TO POTENTIAL STUDENT.
NAME OF POTENTIAL STUDENT
YOUR E-MAIL ADDRESS.
IF CHILD IS NATIVE AMERICAN, PLEASE PROVIDE NAME OF TRIBE.
YOUR PHONE NUMBER(S). *
AGE OF POTENTIAL STUDENT (GOODLAND ONLY ACCEPTS STUDENTS AGES 10 - 13). *
Required
ADDRESS.
CITY.
STATE.
ZIP.
CHECK ALL THAT APPLY TO CHILD.
ADDITIONAL INFORMATION REGARDING TOPICS IN THE ABOVE BEHAVIOR CHECKLIST.
DOES CHILD HAVE ANY OF THE FOLLOWING:
OTHER INFORMATION YOU WOULD LIKE TO PROVIDE.
In accordance with Federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and policies, the USDA, its Agencies, offices, and employees, and institutions participating in or administering USDA programs are prohibited from discriminating based on race,color, national origin, sex, disability, age, or reprisal or retaliation for prior civil rights activity in any program or activity conducted or funded by USDA.Persons with disabilities who require alternative means of communication for program information (e.g. Braille, large print, audiotape, American Sign Language, etc.), should contact the Agency (State or local) where they applied for benefits. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877-8339. Additionally, program information may be made available in languages other than English.To file a program complaint of discrimination, complete the USDA Program Discrimination Complaint Form, (AD-3027) found online at: http://www.ascr.usda.gov/complaint_filing_cust.html, and at any USDA office, or write a letter addressed to USDA and provide in the letter all of the information requested in the form. To request a copy of the complaint form, call (866) 632-9992. Submit your completed form or letter to USDA by:(1) mail: U.S. Department of AgricultureOffice of the Assistant Secretary for Civil Rights1400 Independence Avenue, SWWashington, D.C. 20250-9410;(2) fax: (202) 690-7442; or(3) email: program.intake@usda.gov.This institution is an equal opportunity provider.
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