dynamic-content-widget-5d89096-e410d05 – C. Waldo Scott Center for H.O.P.E.

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Part A- General Information

First Name *

Middle Initial *

Last Name *

Date of Birth: *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address: *

Education History:

Education History

High School Graduate

Obtained G.E.D.

Year Graduated from High School *

Year Obtained G.E.D. *

Last Grade Level Completed *

Vocational programs to which you have applied: *

Name of vocational program you plan to attend: *

Have you been accepted to the vocational program of your choice? *

Yes

Please provide a copy of the letter of acceptance or other official documentation from the vocational program to verify your acceptance. *

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Part B - Residency Information

Are you a U.S. citizen? *

Yes

Are you a resident of the Commonwealth of Virginia? *

Yes

How many years have you lived at your current address? *

Are you able to provide proof of residency? *

Yes

Upload your proof of residency - must be a document that verifies your Southeast Community address, for example a bill or school record *

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If under 18 years old include:

Name of parent/guardian:

Address of parent/guardian:

Phone number of parent/guardian:

Part C - References:

Please provide two (2) letters of reference/recommendation from persons (community residents, church members, co-workers, school personnel, supervisors, etc., but cannot include relatives) to speak to your character, motivation to accomplish your goals, etc. *

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Part D - Certification

I certify that the information I have provided on this application is true and accurate. *

Please write your signature below

Date *

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