Residential Program Residential Program ApplicationPlease read and answer the questions below. If a question does not apply to you, leave the question blank. Today's Date* MM slash DD slash YYYY Name* First Last Name that you wished to be called Date of birth* MM slash DD slash YYYY Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Primary Phone*Work PhoneOther PhoneEmail* Marital Status* Please list all who reside in your home: name, age and relationship to you.Your ethnic origin White African American Asian or Pacific Islander Hispanic American Indian or Native Alaskan Other Information requested is voluntary. It will not be used in making a selection decision, but is collected for institutional research and reporting purposes.Please indicate the education you have received. No high school diploma or GED High school diploma or GED Some college Currently enrolled in college College degree Are you currently employed?* Yes No If yes, how many hours a week do you work? If you have recently stopped working, please state the reason.Please list any volunteer work you may have done in your community, church, or school.Are you currently working with a therapist?* Yes No Please understand that the two-week residential program generally requires physical activities including but not limited to walking (i.e. walking to and from classes, field trips, etc.), climbing stairs, and sitting for long periods of time (i.e. class, riding in a vehicle, etc.). Please also know that the New Opportunity School takes very seriously its role as host to a number of participants each session, and will require each participant to conduct herself in a safe and productive manner.Because the New Opportunity School seeks to serve those of limited financial resources, income will be a strong consideration in choosing participants for the program. Please check the category that best represents your FAMILY income. $0-10,000 per year $10,000-15,000 per year $15,000-20,000 per year If over $20,000 per year, please list the amount per year. *List sources of income. (For example: your work, your husband's work, alimony, welfare benefits, ect.)*List any recent unusual financial difficulties. Please explain.Do you give permission for a background check? A past conviction will not impact your acceptance into our program. Yes No *How did you hear about the New Opportunity School for Women?* There is a limited amount of money available to assist with childcare expenses. Would you need assistance paying for childcare while attending our program? Answer yes or no. There is a limited amount of money available to assist with travel expenses. Would you need assistance paying for travel to attend our program? Answer yes or no. If selected, I agree to attend the two-week program of the New Opportunity School for Women and participate fully in all scheduled activities.Signature of applicant* By typing your name you agree that this represents your signature.Date* MM slash DD slash YYYY IMPORTANT: Attach to this application two letters of recommendation from people who know you well (i.e. ministers, teachers, employers, social workers). Please ask that they describe their relationship to you, how long they have known you, and why they feel you would be a good candidate for this program. They should also include their contact information and phone number on their letter. Please do not use family members.1st Letter of RecommendationMax. file size: 300 MB.2nd Letter of RecommendationMax. file size: 300 MB.Please write one or more pages about why you want to attend the New Opportunity School for Women and how you think it will help you. Feel free to discuss any unique circumstances that you think merit consideration. Without this personal statement and two letters of recommendation, your application will not be considered. You may paste it into the box below or attach it in a file.Or upload your essay here by clicking "choose file."Max. file size: 300 MB.CAPTCHA
