Residential Program Application Today's date: MM slash DD slash YYYY Your name: Name you wish 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 Phone:Email: Relationship status: Married Single In a domestic partnership In a relationship Please list all who reside in your home: name, age and relationship to youEthnicity: White Black Asian American or Pacific Islander Hispanic American Indian or Native Alaskan Other Highest level of 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. The two-week residential program requires physical activities including but not limited to walking, climbing stairs, and sitting for long periods of time. 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. Are you prepared to do this? Yes No Are you currently working with a therapist? Yes No 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 $10,000 - $15,000 $15,000 - $20,000 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, etc.)List any recent 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 and travel expenses.Would you need assistance paying for childcare while attending our program? Yes No Would you need assistance paying for travel to attend our program? Yes No Please write a short essay (300 words or less) 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 are relevant. Without this personal statement and two references, your application will not be considered. You may paste it into the box below or attach it as a file.Or upload your essay here:Max. file size: 300 MB.ReferencesPlease provide the names, phone numbers and email addresses of two references who know you well (i.e., teachers, social workers, employers, ministers, etc.). Name of first reference: First Last Phone number of first reference:Email of first reference: Name of second reference: First Last Phone number of second reference:Email of second reference: 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
