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Single Parent Program Application

Please complete the following information and submit.
* denotes required field

*Student ID #:
Please do not enter a Social Security Number
*Full Name (include Mr./Ms.):

Prefix:  First:  Middle:  Last:  Suffix:

Street/P.O. Box
City, State, Zip      
*Home Phone:

( ) - -

Other Phone:

( ) - -

Date of Birth:
Gender:
Are you a DSS/Work Support participant? Yes   No

Emergency Contact Information

Full Name (include Mr./Ms.):

Prefix:  First:  Middle:  Last:  Suffix:

Relationship:
Home Phone:

( ) - -

Other Phone:

( ) - -

Additional Info Requested

*How many children do you have?
What are their ages?
*Your Educational Level:
Ethnic Origin:
*Gross Family Income:
*Years paid part-time employment:
*Years paid full-time employment:
*Support Services Required:
Other Agency:
*How did you hear about the program?
*Focus of training:
Is training in a non-traditional area? Yes   No

By clicking on the Submit button at the bottom and checking this box, I understand that all of the information on this and any other project record is STRICTLY CONFIDENTIAL. Any information, which might be used for statistical purposes, may contain my name, but will not be released to the general public. I authorize the project to consult with and release any pertinent data to support services, prospective employers, and/or training personnel on my behalf.