Residential Program Application Today's date: MM slash DD slash YYYY Your name:(Required)Name you wish to be called:(Required)Date of birth:(Required) MM slash DD slash YYYY Address:(Required) 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:(Required)Email:(Required) Relationship status:(Required) Married Single In a domestic partnership In a relationship Please list all who reside in your home: name, age and relationship to you(Required)Ethnicity:(Required) White Black Asian American or Pacific Islander Hispanic American Indian or Native Alaskan Other Highest level of education you have received:(Required) No high school diploma or GED High school diploma or GED Some college Currently enrolled in college College degree Are you currently employed?(Required) 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.If you are accepted to the residential program, you will be living with other women for two weeks, sharing rooms, attending classes and eating meals together. This requires patience, flexibility, collaboration and respect. What questions or concerns does this raise for you?(Required)The two-week residential program requires physical activities including but not limited to walking, climbing stairs, and sitting for long periods of time. What questions or concerns does this raise for you?(Required)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.(Required) $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.)(Required)Do you give permission for a background check? A past conviction will not impact your acceptance into our program.(Required) Yes No How did you hear about the New Opportunity School for Women?(Required)NOSW works to remove barriers to your attending our programs. If you qualify, we may be able to assist with a portion of your travel, childcare, and/or lost wage expenses. Would you need assistance with travel, childcare, and/or lost wage expenses?(Required) Yes No What do you hope to gain from attending the residential program?(Required)What challenges have you experienced that would make our program helpful for you?(Required)What work have you done to address these challenges?(Required)What hopes do you have for your future?(Required)
