Information Request Form

If you would like to have a recruiter contact you, please provide the following information.

Which recruiter should contact you? *

Tim Amos--Northern NM

Raymond Pena--Southern NM

K. Dolores Herrera--Recruiting Supervisor

Required

Date of birth *

01/01/2014

YYYY

Age *

Must be 16 on or before the start of a class; and no older that 18 on the day the class starts.

Your answer

First Name *

Your answer

Last Name *

Your answer

Parent/Guardian Email Address *

example@domain.com

Your answer

Address *

123 1st St.

Your answer

City *

Your answer

State *

NMNGYCA is open to NM Residents ONLY

Your answer

Zip Code *

Your answer

County *

Your answer

Gender *

Male Or Female

Male

Female

Required

Parent/Guardian Information

Parent/Guardian First Name *

Your answer

Parent/Guardian Last Name *

Your answer

Relationship: *

Father, Mother, Guardian

Your answer

Phone Number *

(555)-555-5555

Your answer

Best time to call? *

Your answer

Race

American Indian or Alaskan Native

Asian

Native Hawaiian or Pacific Islander

White

Black or African America

Other

Questionaire

Applicant's Statement: Please state why you desire to be accepted to the ChalleNGe program? *

Your answer

Would you like a recruiter to call you? *

Yes

Do you meet one or more of the following? (check all that apply) *

Habitually truant

Drop out

Expelled

Behind in credits

16-18 yrs

Currently on or ever been on probation

Have valid NM ID

Voluntarily applying

Required

Have you ever been adjudicated, indicted, or charged of a felony? *

Yes

If yes, please explain

Your answer

How did you find out about the ChalleNGe? *

Your answer

Comment or Questions

Please leave your comment or question here

Your answer

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