Request for Application This a request for an application only. Fields marked with * are mandatory. Request for ApplicationCadetDate of Birth dd/mm/yy *First name *Middle Name Last Name *Email *Street Address *Apt, Suite, Bldg. (optional) City *State *Zip code *Phone *Race/Ethnicity Gender *MaleFemaleGuardianFirst Name *Middle Name Last Name *Relationship Home Phone Work Phone Cell Phone Applicant questionareHow did you learn about Mississippi Youth Challenge Academy? *TVRadioNews paperWord of MouthSchoolSoc WrkInternet / SMApplicant's Statement: please state why you desire to be accepted to the ChalleNGe Program *Would you like for a staff Member to call you? YesNoBest time to call: Do you meet one or more of the following (check all that apply): *Habitually TruantDrop OutExpelledBehind in creditsHome schoolednone applyHave you ever been charged, or convicted of a felony? YesNo VerificationPlease enter any two digits *Example: 12This box is for spam protection - please leave it blank:
