Please complete the information on this webpage in order to download an application. Submitting this page does not mean you have applied. To begin the application process, you must download the application documents and mail them to the program. Fields marked with * are mandatory.

Applicant Information

Date Of Birth (MM/DD/YYYY)*

First*/Middle/Last* name

Email

Address*

Apt:

City*

ZIP: *

State*

County*

Phone Number*

Race/Ethnicity

Gender*

Parent/Guardian Information

First/Middle/Last name

Relationship

Home Phone

Work Phone

First/Middle/Last name

Relationship

Home Phone

Work Phone

How did you find out about ChalleNGe?

Applicant's Statement: please state why you desire to be accepted to the ChalleNGe Program:

Would you like a recruiter to call you? Yes No Best time to call:

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

habitually truant		drop out
expelled		behind in credits
home schooled		none apply

Have you ever been convicted, indicted, or charged of a felony? Yes No