Request for Application

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.

Applicants Information

Date Of birth (MM/DD/YYYY)*

First Name*

Middle name

Last Name*

Your Email (required)*

Address*

City*

State*

ZIP*

County*

Phone Number*

Race/Ethnicity

Gender*

Parent/Guardian Information


First name

Middle Name

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 for a staff Member to call you? YesNo

Best time to call:

Do you meet on or more of the following(check all that apply): habitually truantdrop outexpelledbehind in creditshome schoolednone apply

Have you ever been convicted, indicted, or charged of a felony? YesNo